Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery.

BACKGROUND: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. METHODS: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. RESULTS: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. CONCLUSION: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.

Formación especializada de residentes en Cirugía Plástica, Reconstructiva y Estética en los países de la Federación Ibero Latinoamericana de Cirugía Plástica (FILACP): consenso de tutores 2022 / Resident training in Ibero Latin American Federation of Plastic Surgery (FILACP) countries: consensus from training directors in 2022

Introducción y objetivo: La formación y la docencia son dos objetivos fundamentales de la Federación Ibero Latinoamericana de Cirugía Plástica (FILACP), entidad compuesta por las Sociedades Nacionales de Cirugía Plástica de 22 países de Ibero Latinoamérica. El objetivo de nuestro trabajo fue poner en común y discutir la situación de la formación especializada en Cirugía Plástica en los diferentes países miembros de la FILACP, en una reunión en la que estuvieron presentes tutores acreditados por cada una de la Sociedades Nacionales de Cirugía Plástica que componen la Federación. Material y método: Se realizaron encuestas y entrevistas personales a tutores y representantes de las sociedades nacionales miembros de la FILACP, en las que se recabó información sobre oferta docente anual y servicios acreditados, proceso de admisión, duración del periodo formativo, financiación de la formación, periodos lectivos anuales, métodos de supervisión y métodos de evaluación. Los resultados obtenidos se contrastaron y pusieron en común durante el Encuentro Internacional de Tutores de la FILACP celebrado en abril de 2022 en San José, Costa Rica. Resultados: En los paises de la Federación se formó en 2021 a un total de 539 residentes en 245 servicios docentes acreditados, siendo aproximadamente la oferta media de 1 residente por cada 700.000 habitantes. El examen fue la principal vía de acceso a la especialidad, cuya duración osciló entre 3 y 5 años, siendo 3 años lo más frecuente. Los periodos lectivos anuales estuvieron en rangos entre 1920 y 4150 horas, siendo la cifra más frecuente en torno a 2500 horas al año. La supervisión por plantilla y el jefe de residentes fueron figuras establecidas en muchos centros, y el examen fue el método de evaluación más extendido. (AU)

Background and objective: Training and teaching are two fundamental objectives of the Ibero-Latin American Federation of Plastic Surgery (FILACP), an entity composed of the National Societies of Plastic Surgery of 22 Ibero-Latin American countries. The aim of our work was to share and discuss the situation of specialized training in Plastic Surgery in the different member countries of FILACP, in a meeting where tutors accredited from all the Plastic Surgery National Societies of the Federation were present. Methods: Surveys and personal interviews were carried out with tutors and representatives of the national societies members of FILACP, in which information was collected on the annual teaching offer and accredited services, admission process, duration of the training period, financing of the training, annual teaching periods, supervision methods and evaluation methods. The results obtained were contrasted and shared during the FILACP International Meeting of Tutors held in April 2022 in San José, Costa Rica. Results: In the Federation countries, a total of 539 residents were formed in 2021 in 245 accredited teaching services, the average supply being approximately 1 resident per 700.000 inhabitants. The examination was the main access route to the specialty, the duration of which ranged from 3 to 5 years, with 3 years being the most frequent. Annual teaching periods ranged from 1920 to 4150 hours, the most frequent figure being around 2500 hours per year. Supervision by staff and chief resident were established figures in many centers, and examination was the most widespread method of evaluation. (AU)

Clinical Outcomes in Ring Avulsion Fingers and Systematic Review of the Literature.

Ring avulsions continue to be a challenge in reconstructive surgery. We conducted a retrospective study and reviewed all Urbaniak-Kay type IV degloving injuries replanted at our institution between 2011 and 2018. A systematic review of the literature was also conducted to assess the survival rates, functional, and sensibility outcomes. The results of our systematic review outline a survival rate of 79.50% (101/127). With 1 artery being repaired, 79% of the fingers survived, a value that increased to 87.50% when 2 arteries were anastomosed (P = 0.484). Statistically significant differences (P < 0.001) were found when comparing the survival rates of the fingers with 2 or more veins repaired (87%) with those with only 1 vein anastomosed (51.90%). In terms of nerve reconstruction, there was a significant difference (P < 0.001) with the 2-point discrimination test in favor of the reconstructed group when nerve reparation was done (10.80 mm ± 2.95 mm) versus when digital nerves were not repaired (15.25 mm ± 0.50 mm). Fingers after secondary procedures did not obtain better mobility. The mean total active motion in nonreoperated fingers was 221 degrees (195-270 degrees), whereas the total active motion in the cases who received secondary surgeries was 152 degrees (110-195 degrees), with statistically significant differences (P = 0.02). Therefore, we recommend attempting replantation of degloved fingers. All efforts must be done to carry out 2 vein anastomoses, and our results strongly recommend attempting at least some kind of nerve reconstruction. Secondary surgeries should be reserved for selected cases only, because of the extensive scarring in this kind of injuries. Early mobilization protocols must be encouraged to achieve a good functional result.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery.

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Outcomes of DIEP Flap and Fluorescent Angiography: A Randomized Controlled Clinical Trial.

BACKGROUND: Breast reconstruction with the deep inferior epigastric perforator (DIEP) flap can be associated with complications such as fat necrosis. The authors' objective was to assess the safety and efficacy of fluorescent angiography with indocyanine green to reduce fat necrosis. METHODS: The authors designed a parallel, randomized, controlled clinical trial for unilateral breast reconstruction. The poorly vascularized tissues of the DIEP flap were removed based on a clinical evaluation in group 1 and based on angiographic criteria in group 2. The authors recorded the flap dimensions, perfusion in terms of fluorescence intensity, complications, reoperations, and BREAST-Q questionnaire scores for both groups. RESULTS: The study included a total of 51 patients. The flaps showed no size differences after the tissue was excised. The flaps of group 2 presented higher perfusion rates (p = 0.001). The incidence of fat necrosis was 59.3 percent in group 1 and 8.3 percent in group 2 (p = 0.001). Four cases of partial necrosis were recorded in group 1 (18.2 percent) compared with none in group 2 (0 percent) (p = 0.131). Four patients underwent reoperation in group 1 (14.8 percent) compared with none in group 2 (0 percent) (p = 0.113). The patients in group 2 reported higher scores in all domains of the BREAST-Q. CONCLUSIONS: Fluorescent angiography with indocyanine green significantly reduced the incidence of fat necrosis without diminishing the flaps' dimensions. The perfusion rates were significantly higher and the patients reported significantly greater satisfaction and quality of life. Fluorescent angiography with indocyanine green may be considered a safe and effective tool to enhance the outcomes of breast reconstruction with the DIEP flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Clinical Significance of Alloantibodies in Hand Transplantation: A Multicenter Study.

BACKGROUND: Donor-specific antibodies (DSAs) have a strong negative correlation with long-term survival in solid organ transplantation. Although the clinical significance of DSA and antibody-mediated rejection (AMR) in upper extremity transplantation (UET) remains to be established, a growing number of single-center reports indicate their presence and potential clinical impact. METHODS: We present a multicenter study assessing the occurrence and significance of alloantibodies in UET in reference to immunological parameters and functional outcome. RESULTS: Our study revealed a high prevalence and early development of de novo DSA and non-DSA (43%, the majority detected within the first 3 postoperative y). HLA class II mismatch correlated with antibody development, which in turn significantly correlated with the incidence of acute cellular rejection. Cellular rejections preceded antibody development in almost all cases. A strong correlation between DSA and graft survival or function cannot be statistically established at this early stage but a correlation with a lesser outcome seems to emerge. CONCLUSIONS: While the phenotype and true clinical effect of AMR remain to be better defined, the high prevalence of DSA and the correlation with acute rejection highlight the need for optimizing immunosuppression, close monitoring, and the relevance of an HLA class II match in UET recipients.

Vascularized composite allotransplantation - a Council of Europe position paper.

After more than 120 hand-upper extremity and 37 face transplant procedures performed worldwide, vascularized composite allotransplantation (VCA) now falls under the scope of organ transplant legislation in Europe and the United States. While in the USA, VCA has been considered as standard care since 2014, VCA in Europe is still performed through clinical research trials, except in United Kingdom. However, after two decades of favourable experience with upper extremity transplantation (UET), professionals in Europe are proposing hand allotransplantation as "controlled standard" care, as opposed to face transplantation (FT), which is still a challenging activity. The European Committee on Organ Transplantation (CD-P-TO) has elaborated a position paper to provide recommendations concerning regulatory aspects for UET and FT. It is aimed at Health Authorities in charge of the oversight - and coordination - of organ donation and transplantation, and at professional groups to help them manage such complex and costly programs dedicated to properly selected patients.

Seguridad y complicaciones en reconstrucción mamaria autóloga con colgajo DIEP: una revisión sistemática / Safety and complications of autologous DIEP flap breast reconstruction: a systematic review

La reconstrucción mamaria microquirúrgica con tejido autólogo puede asociar complicaciones relacionadas con el colgajo y la zona donante. Nuestro objetivo fue valorar la evidencia clínica en seguridad, complicaciones y factores de riesgo en pacientes reconstruidas con colgajo de perforantes basado en la arteria epigástrica inferior profunda (DIEP). Se realizó una revisión sistemática en Medline de artículos publicados entre septiembre de 1995 y septiembre de 2015. Se recogieron las características demográficas de las pacientes, las medidas de los colgajos y las complicaciones de la cirugía incluyendo la necrosis completa, la necrosis parcial y la necrosis grasa. Se identificaron 34 artículos que incluían 35 series de casos, 2.761pacientes y un total de 3.927colgajos. La media del índice de masa corporal fue superior a 24,5kg/m2, mientras que la tasa de obesidad se situó por encima del 14,5%. Ningún artículo aportó información acerca del peso, superficie o volumen del colgajo tras su tallado en la zona receptora. Las tasas de necrosis completa y parcial fueron del 1,9% (75/3.811) y del 2,6% (68/2.575) respectivamente. La necrosis grasa se diagnosticó en el 8,2% (308/3.746) de los colgajos, con una desviación estándar de 6,9. El 5,5% (107/1.940) de los colgajos requirieron reintervención quirúrgica. La incidencia de hematoma en la zona receptora y de hernia o debilidad abdominal fue de un 3% (59/1.952 colgajos y 52/1.725 pacientes). En conclusión, la incidencia de complicaciones en reconstrucción mamaria con colgajo DIEP fue baja, aunque la necrosis grasa presentó una dispersión elevada (AU)

Autologous free flap breast reconstruction may be associated with complications related to the flap and the donor site. Our objective was to evaluate the reported evidence on safety, complications and risk factors in patients undergoing deep inferior epigastric artery perforator flap (DIEP) breast reconstruction. A systematic review was conducted based on a Medline search for studies published between September 1995 and September 2015. Demographic data, flap dimensions and complication rates were recorded including total flap necrosis, partial flap necrosis and fat necrosis. A total of 34 clinical studies including 35 case series, 2,761 patients and 3,927 DIEP flaps were identified. The mean body mass index was higher than 24.5kg/m2 whereas the obesity rate was above 14.5%. None of the articles reported flap weight, area or volume after molding. Total and partial flap necrosis rates were 1.9% (75/3,811) and 2.6% (68/2,575), respectively. Fat necrosis was diagnosed in 8.2% (308/3,746) of flaps with a standard deviation of 6.9. Reoperation was required in 5.5% (107/1,940) of the flaps. The incidence of hematoma in the recipient site and abdominal hernia or bulge formation was 3% (59/1,952 flaps and 52/1,725 patients). In conclusion, the occurrence of complications in breast reconstruction by autologous DIEP flap was low, although the occurrence of fat necrosis ranged widely (AU)

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery.

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Transfusion requirements in burn patients undergoing primary wound excision: effect of tranexamic acid.

BACKGROUND: Early excision of burn wounds is the standard approach for burns, but it is usually associated with the need of allogeneic blood transfusion. Our aim was to determine if intravenous administration of tranexamic acid (TXA) was able to reduce packed red blood cell (pRBC) transfusion requirements in burn patients. METHODS: We conducted a retrospective cohort study of 2 consecutive series of severely burned patients (≥20% total body surface are) admitted for primary burn surgery. We searched for differences in pRBC transfusion occurrence and requirements during surgery and up to 24 hours after surgery. RESULTS: A total of 107 patients were included in the study, and 48.6% (52 patients) received TXA during primary excision. The use of TXA exhibited an absolute risk reduction in the need for transfusion during surgery of 24.2% (95% CI: 7.1-41.4%). In total, patients receiving TXA required 1.6 units of pRBC in the perioperative period vs. 2.6 units in those not receiving TXA (P=0.017). CONCLUSIONS: The intraoperative use of TXA in burn patients undergoing primary burn excision reduced the incidence of allogeneic transfusion and the total number of pRBC transfused.

Algorithmic surgical enhancement of function after finger revascularisation.

Secondary surgical procedures can improve the function of revascularised and replanted digits. We describe the case of a patient who underwent multidigit revascularisation and replantation following a saw injury at flexor tendon Zone II. To achieve maximal functional improvement after finger revascularisation, we performed secondary surgical procedures in an order that was determined by following a reconstructive decision procedure that covered late revascularisation, nerve reconstruction, pedicled vascularised joint transfer, staged flexor tendon reconstruction and skin revision. Performing the procedures in this manner ensured overall safety. The patient's disabilities of the arm, hand and shoulder questionnaire score improved by 45 points, and the patient was able to return to work with an almost complete range of motion.

Effect of Cold Preservation on Chronic Rejection in a Rat Hindlimb Transplantation Model.

BACKGROUND: Previous studies on solid organ transplantation have shown that cold ischemia contributes to the development of chronic allograft vasculopathy. The authors evaluated the effect of cold ischemia on the development of chronic rejection in vascularized composite allotransplantation. METHODS: Thirty rat hindlimbs were transplanted and divided into two experimental groups: immediate transplantation and transplantation after 7 hours of cold ischemia. The animals received daily low-dose immunosuppression with cyclosporine A for 2 months. Intimal proliferation, arterial permeability rate, leukocyte infiltration, and tissue fibrosis were assessed. The CD3, CD4, CD8, CD20, and CD68 cells per microscopic field (200×) were counted, and C4d deposition was investigated. Cytokine RNA analysis was performed to measure tumor necrosis factor-α, interleukin-6, and interleukin-10 levels. RESULTS: Significant differences were found in the intimal proliferation and arterial permeability rate between the two groups (p = 0.004). The arterial permeability rate worsened in the most distal and small vessels (p = 0.047). The numbers of CD3, CD8, CD20, and CD68 were also statistically higher in the cold ischemia group (p < 0.05, all levels). A trend toward significance was observed with C4d deposition (p = 0.059). No differences were found in the RNA of cytokines. CONCLUSIONS: An association between cold ischemia and chronic rejection was observed in experimental vascularized composite allotransplantation. Chronic rejection intensity and distal progression were significantly related with cold ischemia. The leukocyte infiltrates in vascularized composite allotransplantation components were a rejection marker; however, their exact implication in monitoring and their relation with cold ischemia are yet to be clarified.

Safety of salvaging impending flap congestion in breast reconstruction by venous supercharging of the cephalic vein.

Autologous flap breast reconstruction is an established technique that carries a risk of vascular failure. We evaluated the safety of salvaging impending venous congestion by using the cephalic vein for supercharging autologous abdominal flaps. Our main outcome measures were flap survival, triggering or impairing lymphedema as measured by the physician or reported by the patient, and scar severity as measured by the Vancouver scar scale. We were able to save 100% of the flaps, but could not find any statistical association with or without increased lymphedema before and after the procedure. One patient reported that lymphedema worsened. The patients accepted the scars (mean Vancouver scar scale score, 5.7). In sum, using the cephalic vein to improve venous drainage of autologous breast reconstruction was safe and did not trigger or impair lymphedema, but scarring in the upper arm was unavoidable.