Synthetic Simulators for Microsurgery Training: A Systematic Review.

Background: Microsurgery has a steep learning curve. Synthetic simulators have proven to be useful training tools for the initial learning stages, as well as being ethically sound, viable, safe, and cost-effective. The objective of this review was to determine the quality, effectiveness, and validity of these simulators as well as to assess their ability to evaluate microsurgical skills. Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. We searched databases (Web of Science, Scopus, and PubMed) to identify original articles describing synthetic training models for microsurgery. Three reviewers evaluated articles for inclusion following predefined selection criteria. Data were extracted from full-texts of included articles. Results: Thirty-nine studies met the inclusion criteria. A total of 38 different devices have been recorded. Microsurgical training devices offer a low-cost, fast, and consistent method to concretely quantify and assess the initial microsurgical skills of trainees using standardized exercises that can be scored by the examiner. According to the authors, the outcomes were satisfactory, with a tangible improvement in microsurgical abilities, despite the lack of a common comparison scale. Conclusions: Thanks to their availability, cost, and effectiveness, synthetic models are the recommended option to train basic, intermediate and advanced procedures before executing them on in vivo models.

Modified Gritti-Stokes amputation: tips and tricks.

Major amputations of the lower extremity may be required after trauma and a variety of underlying diseases such as peripheral vascular disease, diabetes, and malignancies. The goal of any major amputation is an optimal functional result with a maximum limb length in combination with optimal wound healing. The preservation of the knee joint is essential for successful rehabilitation, and this is best achieved by the Burgess below-knee amputation (BKA). Whenever a BKA is not possible, the Gritti-Stokes amputation is our first choice. This technique mainly consists of a through-knee amputation with the creation of a pedicled patella flap consisting of the patella, patellar ligament, and overlying soft tissue. After osteotomy of the distal femur and resection of the articular surface of the patella, the anterior flap is rotated in order to cover the femur defect while performing a patellofemoral arthrodesis. The aim of this paper is to describe our surgical technique and experience with GSA and to point out the important steps of this procedure. In conclusion, GSA is an excellent surgical option for patients requiring major lower limb amputations where BKA cannot be considered. Particular attention must be paid to careful preoperative evaluation and optimization of comorbidities. A meticulous surgical technique is warranted, including atraumatic tissue handling and an optimal patellofemoral arthrodesis technique.

The Promise and Pitfalls of AI-Generated Anatomical Images: Evaluating Midjourney for Aesthetic Surgery Applications.

BACKGROUNDS: The rapid advancement of generative artificial intelligence (AI) systems, such as Midjourney, has paved the way for their use in medical training, producing computer-generated images. However, despite clear disclosures stating that these images are not intended for medical consultations, their accuracy and realism are yet to be thoroughly examined. METHODS: A series of requests were addressed to the Midjourney AI tool, a renowned generative artificial intelligence application, with a focus on depicting appropriate systemic anatomy and representing aesthetic surgery operations. Subsequently, a blinded panel of four experts, with years of experience in anatomy and aesthetic surgery, assessed the images based on three parameters: accuracy, anatomical correctness, and visual impact. Each parameter was scored on a scale of 1-5. RESULTS: All of images produced by Midjourney exhibited significant inaccuracies and lacked correct anatomical representation. While they displayed high visual impact, their unsuitability for medical training and scientific publications became evident. CONCLUSIONS: The implications of these findings are multifaceted. Primarily, the images' inaccuracies render them ineffective for training, leading to potential misconceptions. Additionally, their lack of anatomical correctness limits their applicability in scientific articles. Although the study focuses on a single AI tool, it underscores the need for collaboration between AI developers and medical professionals. The potential integration of accurate medical databases could refine the precision of such AI tools in the future. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls.

Background Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review.

Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.

Artistry and Aesthetics in Breast Reconstruction: Raising the Bar.

Breast reconstruction is a critical component of breast cancer treatment for many women who undergo mastectomy [...].

Time to return to work after total trapeziometacarpal prosthesis.

OBJECTIVES: This study assessed return to work and prosthesis survival after trapeziometacarpal prosthesis surgery. MATERIAL AND METHODS: A multicenter retrospective study was carried out on patients operated on between 2002 and 2020. All working patients who had undergone trapeziometacarpal prosthesis surgery were included. Return to work was defined as resuming the same full-time position. Postoperative events and their specific treatment and failure to return to work were reported. RESULTS: 240 prostheses in 211 patients were included. The complications rate was 7.5%, with 97% prosthesis survival. 94.3% of patients returned to work, at a mean 48 days (range, 29-210 days; SD, 22.7 days), with no significant difference according to age. Twelve patients did not return to work, half of whom because of prosthetic complications. CONCLUSION: Trapeziometacarpal arthroplasty enables most patients to return to work within 6 weeks. In this series, the prosthetic survival rate was 97%.

Quality of life and sexual health after perineal reconstruction in Fournier gangrene using pedicled anterolateral thigh flaps.

Objectives: To assess long-term sexual outcome and quality of life after perineal reconstruction by pedicled anterolateral thigh (ALT) flaps after Fournier's gangrene. Postoperative surgical outcomes were assessed; quality of life and sexual function were assessed at long term follow-up (>12 months) with 2 scientifically validated questionnaires. Methods: We conducted a retrospective analysis of a prospectively maintained database. Long-term sexual function and quality of life were assessed by standardized questionnaires. Descriptive statistics were conducted. Results: 8 patients were included in our study, 5 patients responded to quality of life and sexual function analysis. Surgical outcomes were in line with literature: one minor complication (minor dehiscence requiring a skin graft), one major complication (flap loss, requiring a second, contralateral flap) occurred. No reconstructive failure occurred. Average time to complete wound healing was 17 days (SD ±5). Quality of life scores over 70/100 in four out of five categories; social function was rated lowest: patients reported very few residual complaints. Sexual outcome analysis emphasizes the positive impact of the reconstruction. As expected, Fournier's Gangrene heavily affected patient's sexual health. Conclusions: Perineal reconstruction with ALT shows excellent quality of life, and good sexual health outcomes. Currently the lack of reliable and relatable data leads to the impossibility to compare different reconstructive procedures. We emphasize that assessing sexual function and quality of life after perineal reconstruction is paramount to weigh reconstructive success.

Total Urethra and Penile Shaft Reconstruction with Combined Pedicled Anterolateral Thigh Flap and Radial Forearm Free Flap after Total Penectomy.

Total reconstruction of the penis (TPR) represents a challenge for urologists and plastic surgeons, especially when urethral length is severely reduced. We here describe, for the first time in an oncologic scenario, a double flap phalloplasty using a pedicled anterolateral thigh (ALT) flap for penile reconstruction and a radial forearm free flap (RFFF) for complete neourethra and glans reconstruction following penile amputation. A 48-year-old patient came to our department following a total penectomy with inferior urethral derivation. The indication for a double flap phalloplasty was posed as only way to fully reconstruct the urethra on its length avoiding possible complications of single flap reconstruction using tube-into-tube technique. Both flaps healed uneventfully with no neourethral strictures or fistulas described. At 18 months follow-up, the patient was extremely satisfied with the aesthetic result and was able to void in standing position. We think that a double free tissue transfer for TPR should be considered, particularly when a urethral length > 14 cm needs to be reconstructed. While the pedicled ALT can be used to reconstruct a proper penile shaft with an easily concealed scar, the RFFF can provide adequate neourethra length with satisfactory sensory recovery at the neoglans.

Evaluation of long-term breast shape in inferior versus superomedial pedicle reduction mammoplasty: a comparative study.

BACKGROUND: Among breast reduction mammoplasty, the inferior pedicle-based (IFP) technique is considered the most performed by plastic surgeons. A growing interest for the supero-medial based pedicle (SMP) mammoplasty technique has been documented in literature and clinical practice. However, no real evidence exists on the superiority of one technique over another. METHODS: This study represents a retrospective multimodal analysis, using a prospectively maintained database, comparing wise pattern breast reduction techniques (IFP vs. SMP) over a 24-month follow-up. From January 2015 to July 2017, all patients undergoing wise pattern bilateral reduction mammoplasty, using either an IFP or a SMP technique, were included in the study and divided in two groups. Pre-operative breast measurements included sternal notch-to-nipple distance (SN-N), infra-mammary fold to inferior border of Nipple Areolar Complex (NAC) distance length and ptosis. The same measurements were recorded at 2 weeks, 6 months and 24 months post-op. Complications were recorded and aesthetic outcomes were evaluated. RESULTS: A total of 58 patients were included in the study, among which 36 (62%) were treated with a SMP technique and 22 (38%) with an IFP technique. At the 24-month follow-up timepoint, the SN-N distance was significantly shorter (*P<0.05) in the SMP group, with a significantly smaller elongation of the lower pole arc (29.5% increase in length in the SMP group and 40.9% in the IFP group). Aesthetic result gave significantly higher mean VAS score for SMP patients compared to IFP patients. CONCLUSIONS: The SMP technique provides stable and satisfactory results in term of breast shape, overcoming some of the major concerns related to the use of an IFP technique (lower pole elongation and ptosis recurrence), maintaining a superimposable complication rate.

The proximal ulnar perforator flap (PUPF) for hand digital reconstruction: an anatomical study.

Degloving injuries of the fingers represent a reconstructive challenge. Even if poorly described in literature, the proximal ulnar perforator flap (PUPF), based on perforator of the anterior ulnar recurrent artery or directly on a perforator branch of the ulnar artery, meets the requested criteria for the ideal coverage. We performed a cadaveric study in order to clarify the anatomical basis and vascularization of the PUPF flap. Eight injected upper limb specimens were dissected for this study: perforators were followed down to their origin and classified in terms of number, length, diameters and distances between their emergence and specific pre-determined landmarks as the medial humeral epicondyle. At least one ulnar perforator in the proximal third of the forearm was identified in all the specimens. In 50% of the upper limbs, the perforator branch came directly from the ulnar artery, while in the 87.5% a perforator branch came from the anterior recurrent ulnar artery; in 3 out of 8 cases both perforator branches were described. Mean lengths of the perforator branch were 57.9 mm and 44.3 mm, respectively and the mean diameters measured at their origin were 0.99 mm and 1.17 mm respectively. Our data illustrate the consistency of at least one perforator branch from the proximal third of the ulnar artery, most commonly coming from the anterior recurrent ulnar artery. Considering our results, the PUPF could be a good alternative to the classical free flaps for the resurfacing of the finger defects.

Anterolateral Thigh Flap With Vascularized Fascia Lata Associated With Thigh Flaps: A Case Report of an All-in-One Reconstruction of the Suspensory Ligament and Penoscrotal District After Fournier Gangrene.

Radical surgical debridement after Fournier gangrene (FG) can totally change anatomical balance between structures and compromise urogenital function. This is particularly true when the suspensory ligament and the lower abdominal wall are involved, leading to erection and sexual intercourse dysfunction.We present the case of a 48-year-old man, who underwent emergency debridement and split-thickness skin graft (STSG) of inferior abdominal wall, pubis, scrotal bag and penile shaft after Fournier gangrene.Five months after the emergency procedure, bilateral medial thigh flaps recreated the scrotal compartment, whereas a pedicled composite anterolateral thigh flap including fascia lata could cover the lower abdominal wall and rebuilt the penile suspensory ligament (PSL).Healing was uneventful and the patient returned to a normal sexual life with satisfactory erection and intercourse.Composite and/or chimeric anterolateral thigh fascia lata flaps have been previously used as a reliable option for complex defects, including tendon and ligaments. We describe here, the first case in the literature of a penile suspensory ligament reconstruction.

Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm.

BACKGROUND: Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity. OBJECTIVES: This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer. METHODS: Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm. RESULTS: Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention. CONCLUSIONS: A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

Reverse-Flow Versus Perforator Propeller Lateral Arm Flap for Elbow Reconstruction.

BACKGROUND: The lateral arm flap (LAF) represents an attractive option for elbow reconstruction, due to low donor site morbidity and a consistent surgical anatomy. It has been described as reverse-flow and as perforator propeller flap (radial collateral artery perforator [RCAP]). We compared the 2 techniques in terms of immediate- and long-term outcomes, together with functional and aesthetic evaluation. METHODS: We retrospectively reviewed 15 patients, 9 males and 6 females, according to the department prospectively maintained database. Ethiology of the defects and patient comorbidities were listed together with flap and clinical data (operative time, time to healing, hospital stay, etc). Functional outcomes were measured according to Quick Disability of Arm Shoulder and Hand score at the time of the last follow-up. RESULTS: Seven LAF flaps were raised in a reverse-flow fashion, whereas 8 were RCAP flaps. No patients described any major elbow functional limitations, and they were generally satisfied with the aesthetic appearance. When comparing the 2 groups of reconstruction, harvest of RCAP flap resulted significantly faster and patients needed less hospitalization days (*P < 0.05). Aesthetic scores were lower where a cutaneous bridge was left intact during rotation (leading to a dogear), which was always the case in reverse-flow flap. Among complications, a partial RCAP flap necrosis occurred in a highly comorbid patient and required a skin graft coverage, whereas 4 reverse-flow flaps presented distal venous congestion which, in 1 patient, led to a secondary flap procedure. CONCLUSIONS: In our practice, elbow reconstruction using the RCAP flap required less hospital stay and operative time. Being less prone to venous congestion, in presence of sizeable perforators, it should be preferred to the reverse-flow LAF flap.

Deep sternal wound infections: Evidence for prevention, treatment, and reconstructive surgery.

Median sternotomy is the most popular approach in cardiac surgery. Post-sternotomy wound complications are rare, but the occurrence of a deep sternal wound infection (DSWI) is a catastrophic event associated with higher morbidity and mortality, longer hospital stays, and increased costs. A literature review was performed by searching PubMed from January 1996 to August 2017 according to the guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following keywords were used in various combinations: DSWI, post-sternotomy complication, and sternal reconstruction. Thirty-nine papers were included in our qualitative analysis, in which each aspect of the DSWI-related care process was analyzed and compared to the actual standard of care. Plastic surgeons are often involved too late in such clinical scenarios, when previous empirical treatments have failed and a definitive reconstruction is needed. The aim of this comprehensive review was to create an up-to-date operative flowchart to prevent and properly treat sternal wound infection complications after median sternotomy.

A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures.

INTRODUCTION: Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL. METHODS: A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or "surgical treatment"), evaluating outcomes, and complications after surgical treatment of GL. RESULTS: Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%. CONCLUSIONS: This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.

Late avulsion of a free flap in a patient with severe psychiatric illness: Establishing a successful salvage strategy.

Post-traumatic defects of the distal third of the leg often require skipping a few steps of the well-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patient has psychiatric illness affecting compliance with postoperative care. We describe a case of a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissue defect was covered with a free gracilis flap. On postoperative day 7, the patient ripped out the newly transplanted flap. The flap was too traumatized for salvage, so a contralateral free gracilis muscle flap was used. The patient showed good aesthetic and functional outcomes at a 1-year follow-up. When planning the postoperative management of patients with psychiatric illness, less complex and more robust procedures may be preferred over a long and complex surgical reconstruction requiring good compliance with postoperative care. The medical team should be aware of the risk of postoperative collapse, focus on the prevention of pain, and be wary of drug interactions. Whenever necessary, free tissue transfer should be performed despite potential compliance issues.