How to Start and Build Microsurgery Practice-Topics on Success and Sustainability: Global/International.

Many young microsurgeons begin their careers at established hospitals where microsurgery resources are limited. This article shares the authors' experiences in overcoming challenges and establishing a microsurgery practice in a new hospital. Due to the lack of equipment, limited support from colleagues, absence of discussion partners, fear of failure, and unpredictable situations, many aspiring microsurgeons lose their motivation. The purpose of this article is to guide future microsurgeons by describing the author's actions and suggesting improvements for their first free flap case. Key factors for building a successful, sustainable, and enjoyable microsurgery practice include remembering your training and mentors, acquiring fundamental knowledge of microsurgery, creating a supportive ecosystem, and having fun.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients.

Background This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p = 0.659, r = - 0.041), and amount of limb volume reduction ( p = 0.454, r = - 0.070) showed no statistical significance. Conclusion The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Septal Reposition During Intermediate Cleft Rhinoplasty: A Second Chance for Correcting Caudal Septal Deviation.

BACKGROUND: We investigated postoperative nasal morphology changes in patients undergoing secondary correction of cleft lip nose with septal repositioning and alar cartilage suspension during preschool age. METHODS: We performed a retrospective review on 77 patients who underwent secondary correction of cleft lip nose. The patients were aged 5‒6 years and underwent intermediate rhinoplasty by alar cartilage suspension, with or without septal repositioning. They were divided into two groups based on time: septal repositioning (Sep. 2015-Nov.2017) and control (Nov. 2009-Aug. 2015) groups. We performed a photogrammetric comparison by assessing the postoperative nasal morphology changes using linear and angular parameters. The cleft-to-non-cleft side ratio of each parameter was measured for the nostril width and height, nostril area, and caudal septal deviation angle. RESULTS: Among the 77 patients, 43 were selected as the septal repositioning group and 34 as the control. The evaluation timing was 5.32 ± 0.45-year-old for the preoperative period (T0), 6.57 ± 0.5-year-old for short-term (T1), and 9.28 ± 0.65-year-old for long-term follow-up (T2). The septal repositioning group showed significantly improved nostril width ratio and caudal septal deviation angle in the T1 and T2 periods. The septal repositioning significantly decreased the nostril area ratio in the T1 and T2 periods due to decreased cleft side and increased non-cleft side nostril area. CONCLUSIONS: The secondary correction of cleft lip nose with septal repositioning during preschool age offers a second chance to correct nasal appearance by balancing the nostril symmetry and correcting the caudal septal deviation.

Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques.

BACKGROUND: Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue. METHODS: This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation. RESULTS: Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy. CONCLUSION: These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis.

BACKGROUND: In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. METHODS: We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. RESULTS: Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). CONCLUSION: Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

Comparative Analysis between Side-to-End and End-to-End Lymphaticovenous Anastomosis for Secondary Lower Limb Lymphedema.

BACKGROUND: The purpose of this retrospective study was to describe, evaluate, and compare the outcome between end-to-end and side-to-end lymphaticovenous anastomoses for all stages of lymphedema. METHODS: A total of 123 patients were divided into the end-to-end ( n = 63) or the side-to-end ( n = 60) group. The demographics and intraoperative and postoperative findings were evaluated. In addition, subcategory evaluation was performed for early- and advanced-phase lymphedema. RESULTS: The demographic findings were insignificant. The intraoperative findings showed a significantly higher number of lymphaticovenous anastomoses performed for the end-to-end group (4.1 ± 1.7) over the side-to-end group (3.2 ± 1.2) ( p < 0.001), whereas the number of different lymphatic vessels used per patient was not significant (3.4 ± 1.4 versus 3.2 ± 1.2; p = 0.386). The diameter of the lymphatic vessels was not significant (0.43 ± 0.06 mm versus 0.45 ± 0.09 mm; p = 0.136). Although both groups showed significant postoperative volume reduction, the side-to-end group had a significantly better reduction in all time intervals ( p < 0.03) and longitudinal outcome ( p = 0.004). However, the subcategory evaluation for early-phase patients showed no difference between the two groups, but a significantly better volume reduction ratio was noted for the side-to-end group at all time intervals ( p < 0.025) in addition to overall longitudinal outcome ( p = 0.004) in advanced lymphedema patients. CONCLUSIONS: This is the first study to report the efficacy of end-to-end versus side-to-end lymphaticovenous anastomosis in different phases of lymphedema. Although both end-to-end and side-to-end lymphaticovenous anastomoses are significantly effective in volume reduction, there was a significantly better reduction for the side-to-end group in advanced-phase lymphedema patients with stage II late and stage III disease, whereas no difference was noted for early-phase lymphedema patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Retrospective Case Series on Free Flap Reconstruction for Ischemic Diabetic Foot: The Nutrient Flap Further Explained.

BACKGROUND: This retrospective case series compares the outcomes and postoperative oxygen levels in patients who underwent free flap versus primary closure/local flap reconstruction for ischemic diabetic foot wounds to determine the influence of free flap on the surrounding ischemic tissues. The authors hypothesized that the free flap would benefit the surrounding ischemic tissue as a nutrient flap by increasing the tissue oxygen content. METHODS: The patients were divided into two groups: group 1 underwent free flap reconstruction, and group 2 underwent partial foot amputation with primary closure/local flap. Patient demographics, endovascular intervention, surgical outcome, postreconstruction intervention, and prereconstruction and postreconstruction transcutaneous oximetry were analyzed. RESULTS: Among 54 patients, 36 were in group 1 and 18 were in group 2. There were no differences in patient demographics between the two groups. All patients had successful angioplasty. Statistical significance was noted in postreconstruction intervention in which group 2 required 2.8 ± 2.9 débridements (versus 1.2 ± 2.5 for group 1) and seven of 18 below-knee amputations (versus three of 36 for group 1) (p < 0.05). Transcutaneous partial pressure of oxygen levels were significantly higher in group 1 at 6 months after reconstruction (61.6 ± 7.5 versus 32.6 ± 5.8 mmHg) (p < 0.01). CONCLUSION: This study shows that the role of the free flap in ischemic diabetic limb may expand beyond that of providing coverage over the vital structures, and it supports the use of the free flap as a nutrient to increase oxygen content in the ischemic diabetic foot. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps.

BACKGROUND: Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS: A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS: Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS: Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Clinical Applications of Augmented Reality Technology in Microsurgical Planning of Head and Neck Reconstruction.

BACKGROUND: To perform head and neck reconstruction, the exact location of recipient vessels must be evaluated preoperatively. This study aimed to superimpose arterial and venous pathways identified by computed tomography angiography (CTA) on patients using augmented reality (AR) techniques to freely select recipient vessels. METHODS: Patients who underwent reconstructive microsurgery due to defects on the scalp, forehead, and glabella from July 2019 to October 2019 were enrolled. The superficial temporal artery (STA) and superficial temporal vein (STV) were marked using hand-held Doppler. Furthermore, the three-dimensional reconstructed CTA image was superimposed on the patient's face using a smartphone application, Camera-Lucida, and marked. The accuracy of mapping was evaluated intraoperatively. Success rates and the time consumed for mapping were compared. RESULTS: Twelve patients underwent preoperative marking. Success rates of STA mapping using the AR technology and hand-held Doppler were 100% and 83%, respectively (P = 0.48). The mean time consumed for STA marking was 90.2 ±â€Š17.7 seconds and 121.0 ±â€Š117.7 seconds, respectively (P  = 0.75). The success rate of STY marking with the AR technology was superior to that with hand-held Doppler (100% versus 58.3%; P = 0.037). STY marking was faster with the AR technology than with hand-held Doppler (mean time, 91.2 ±â€Š25.7 seconds versus 94.5 ±â€Š101.6 seconds; P = 0.007). CONCLUSIONS: The AR technology could be the paradigm shift in the field of microsurgical reconstruction. it can connect threedimensional CTA data with patient topography, leading to not only more precise operations but also improved outcomes in patients undergoing microsurgical reconstruction.