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Journal of Plastic, Reconstructive &... Jul 2022Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.
METHODS
Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.
RESULTS
Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).
CONCLUSION
This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.
REVIEW REGISTRATION
Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.
Topics: Free Tissue Flaps; Head; Humans; Mammaplasty; Microsurgery; Neck; Postoperative Complications; Plastic Surgery Procedures
PubMed: 35643598
DOI: 10.1016/j.bjps.2022.04.028 -
Acta Otorhinolaryngologica Italica :... Apr 2024In carotid paraganglioma surgery, magnification is crucial to properly evaluate the anatomical relationships between mass, carotid wall, cranial nerves, tumour vascular...
OBJECTIVES
In carotid paraganglioma surgery, magnification is crucial to properly evaluate the anatomical relationships between mass, carotid wall, cranial nerves, tumour vascular supply and fascial envelope. The aims of this study are to describe the microsurgical technique, along with the underlying microsurgical anatomy, and to assess outcomes in terms of disease control, complications and functional results.
METHODS
Twenty-six patients, accounting for 29 carotid paragangliomas, treated with microsurgery by the same senior surgeon over a 35-year period, were included.
RESULTS
No carotid injury requiring repair, nor peri- or post-operative stroke occurred in this series. No surgical injury of the main trunk of VII to XII cranial nerves occurred. Complete excision was obtained in all cases and no recurrence was observed during follow-up.
CONCLUSIONS
The small study size and its retrospective nature suggests caution; however, our results show that microsurgery can allow a safe and precise dissection of the carotids and nerves.
Topics: Humans; Carotid Body Tumor; Microsurgery; Middle Aged; Male; Female; Retrospective Studies; Adult; Aged
PubMed: 38651551
DOI: 10.14639/0392-100X-N2761 -
The British Journal of Ophthalmology Aug 2019Pars plana vitrectomy is a challenging, minimally invasive microsurgical procedure due to its intrinsic manoeuvres and physiological limits that constrain human... (Review)
Review
Pars plana vitrectomy is a challenging, minimally invasive microsurgical procedure due to its intrinsic manoeuvres and physiological limits that constrain human capability. An important human limitation is physiological hand tremor, which can significantly increase the risk of iatrogenic retinal damage resulting from unintentional manoeuvres that affect anatomical and functional surgical outcomes. The limitations imposed by normal physiological tremor are more evident and challenging during 'micron-scale' manoeuvres such as epiretinal membrane and internal limiting membrane peeling, and delicate procedures requiring coordinated bimanual surgery such as tractional retinal detachment repair. Therefore, over the previous three decades, attention has turned to robot-assisted surgical devices to overcome these challenges. Several systems have been developed to improve microsurgical accuracy by cancelling hand tremor and facilitating faster, safer and more effective microsurgeries. By markedly reducing tremor, microsurgical precision is improved to a level beyond present human capabilities. In conclusion, robotics offers potential advantages over free-hand microsurgery as it is currently performed during ophthalmic surgery and opens the door to a new class of revolutionary microsurgical modalities. The skills transfer that is beyond human capabilities to robotic technology is a logical next step in microsurgical evolution.
Topics: Humans; Microsurgery; Ophthalmologists; Robotics; Tremor; Vitrectomy
PubMed: 30573495
DOI: 10.1136/bjophthalmol-2018-313318 -
Clinics in Plastic Surgery Oct 2020This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is... (Review)
Review
This article summarizes the major changes seen in lymphatic microsurgery and microvascular surgery in first 20 years of the 21st century. Lymphatic microsurgery is discussed first, as more advances have been seen in imaging of the lymphatic system, lymphatico-venous anastomosis, and vascularized lymph node transfers. During the past 2 decades, there have been more patient population changes than major technical evolutions in microvascular surgery, although new techniques and modifications emerged and became clinical routines, with the landscape of microvascular surgery evolving in this time period.
Topics: Anastomosis, Surgical; Humans; Lymphatic Vessels; Microsurgery; Vascular Surgical Procedures
PubMed: 32892809
DOI: 10.1016/j.cps.2020.07.004 -
International Dental Journal Oct 2022This study aimed to compare the healing outcomes of endodontic microsurgery (EMS) using 2-dimensional (2D) and 3-dimensional (3D) radiographic evaluation in a Chinese...
OBJECTIVE
This study aimed to compare the healing outcomes of endodontic microsurgery (EMS) using 2-dimensional (2D) and 3-dimensional (3D) radiographic evaluation in a Chinese population. The prognostic factors of EMS were identified according to the 2D and 3D healing classifications.
MATERIALS AND METHODS
The teeth (n = 82) were studied using 2D and 3D radiographic examinations. The 2D and 3D healing criteria were used to evaluate the healing outcome. Prognostic factors were investigated based on healing outcomes. Data were analysed using SPSS, and P < .05 was considered significant.
RESULTS
There were significant differences between 2D and 3D healing outcomes (P = .004). For the 3D images, age older than 45 years was found to be a significant negative predictor (P = .005).
CONCLUSIONS
Cone-beam computed tomographic images provided more precise evaluation of periapical lesions and healing outcomes of EMS than conventional periapical radiographs. Age (>45 years) of the patients exhibited a significant influence on the healing outcome of EMS as determined using 3D images.
Topics: Cone-Beam Computed Tomography; Humans; Microsurgery; Middle Aged; Prognosis; Wound Healing
PubMed: 35331471
DOI: 10.1016/j.identj.2022.02.007 -
Journal of Plastic, Reconstructive &... Jul 2022Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery.
INTRODUCTION
Our objective was to measure the impact of a basic microsurgery training course on trainees' confidence and workload in performing microsurgery.
METHODS
A prospective study of participants in an accredited 5-day microsurgery course over a 3-month period. The confidence and workload of the participants were assessed after the first and final day. The workload was assessed using the validated NASA Task Load Index composed of 6 subscales scored on a 20-point visual analog scale (VAS). Confidence was assessed over 5 dimensions on a 5-point VAS for anastomosis performance, vessels preparation, knot tying, training effectiveness, and future practice of microsurgery.
RESULTS
A total of 31 participants completed the study with 55% reporting some previous microsurgery experience. All confidence dimensions improved significantly after completing the course, regardless of prior experience (p<0.01). Those with prior experience started and finished the course at higher confidence levels in anastomosis performance and vessel preparation than the non-experienced group (p<0.05). Overall workload showed a downward trend (improvement) at the end of the course, but no significant changes in the experienced and non-experienced groups (p>0.05). Most participants scored above the 50% "sustainability threshold" for mental demand, both before (71%) and after the course (73%), however, perceived physical demand significantly reduced, p = 0.01.
CONCLUSION
The microsurgery course teaches fundamental skills and principles; therefore, it has merit in those who will utilize these skills in their future practice. Although there is increased confidence in skill acquisition, the impact on perceived workload during a short 5-day basic microsurgery course did not significantly change.
Topics: Anastomosis, Surgical; Clinical Competence; Humans; Microsurgery; Prospective Studies; Workload
PubMed: 35346609
DOI: 10.1016/j.bjps.2022.02.004 -
Journal of Reconstructive Microsurgery Mar 2022Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result.
BACKGROUND
Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result.
METHODS
Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel.
RESULTS
Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery.
CONCLUSION
As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.
Topics: Anastomosis, Surgical; Microsurgery; Plastic Surgery Procedures; Surgical Flaps; Ultrasonography, Doppler, Duplex
PubMed: 35108731
DOI: 10.1055/s-0041-1740218 -
Clinical Neurology and Neurosurgery Dec 2022The global increase in the "ultra-geriatric" population (aged 80 years and older) has led to higher demand for neurosurgical procedures in this vulnerable population.... (Review)
Review
OBJECTIVE
The global increase in the "ultra-geriatric" population (aged 80 years and older) has led to higher demand for neurosurgical procedures in this vulnerable population. The objective was to evaluate the safety and efficacy of advanced microsurgical procedures on ultra-geriatric patients, in our modern era of neurosurgery, anesthesiology, and advanced medical care.
METHODS
The study examined 66 complex cranial procedures, performed on 65 ultra-geriatric patients, who constituted 3.8% of the 4461 consecutive neurosurgical procedures performed by a single neurosurgeon over 14-years in a tertiary care university hospital. Excluded from this study were intra- or extra-axial spontaneous hematomas or traumatic brain injuries, infections, biopsy-only cases and carotid endarterectomies.
RESULTS
The most common indication for surgery for the 66 complex cranial procedures were meningiomas (23.9%), followed by gliomas (17.9%), and metastatic brain tumors (17.9%). Postoperative complications occurred in seven procedures (10.60%). No patient deaths were directly caused by intra- or postoperative events, and only one 30-day mortality occurred. All deceased patients had a statistically significant higher American Society of Anesthesiologists (ASA) class (p = 0.024). However, there was no significant correlation between ASA class and modified Rankin scale at discharge (p = 0.238).
CONCLUSION
With the aging global population and increasing life expectancy, the number of ultra-geriatric patients with complex pathologies seeking advanced microsurgical treatment is growing. Therefore, neurosurgeons are confronting a growing number and variety of complex pathologies in ultra-geriatric patients in their daily practice. Regardless of advanced age, microsurgery provides safe and effective treatment, with age alone not being a barrier to proper neurosurgical treatment when other risk factors are adequately modified.
Topics: Aged; Humans; Microsurgery; Neurosurgical Procedures; Neurosurgery; Meningioma; Postoperative Complications; Meningeal Neoplasms
PubMed: 36332417
DOI: 10.1016/j.clineuro.2022.107500 -
Journal of Reconstructive Microsurgery May 2022Even standard microvascular tissue transfers are time consuming, require great skill and intensity, and can be stressful. Not surprisingly, work-related relative...
BACKGROUND
Even standard microvascular tissue transfers are time consuming, require great skill and intensity, and can be stressful. Not surprisingly, work-related relative value units are considered by many microsurgeons to be suboptimal. Some might even say that "free flaps" indeed really are "free" flaps.
METHODS
A retrospective review of related finances was undertaken for all free flaps performed in a single surgeon private practice during the latest possible year (2014) that included a complete 5-year follow-up to insure receipt of all expected reimbursements from accounts receivable. There were 61 free flaps available; but arbitrarily 12 free flaps were excluded since postmastectomy breast reconstruction always received mandatory insurance payment, as were additional two cases done pro bono as part of an international educational service. This left 47 free flaps to permit determination of gross payments, if any.
RESULTS
Compensation summated for three distinct time intervals for all free flaps was : $10,855.92 (mean: $230.98/flap); : $117,015.46 (mean: $2,489.69/flap); and : $45,296.28 (mean: $963.75/flap). Range of gross payment for the free flap portion only was 529.65 to $4,503.71. Total overall revenue received was $173,167.66 (mean: $3,684.42/flap).
CONCLUSION
A true benefit cost-analysis even if microsurgery specific expenses could be estimated would be inaccurate, so that mean net income for each free flap could not be determined. Albeit a minimal gross payment was obtained for some free flap procedures, in no instance was there reimbursement. Based on that fact, there were no truly "free" free flaps in this private practice experience, which should encourage the younger surgeon to realize that economic viability is possible so that their enthusiasm for reconstructive microsurgery can be sustained.
Topics: Breast Neoplasms; Female; Free Tissue Flaps; Humans; Mammaplasty; Mastectomy; Microsurgery; Postoperative Complications; Plastic Surgery Procedures; Retrospective Studies
PubMed: 34404101
DOI: 10.1055/s-0041-1732429 -
Journal of Reconstructive Microsurgery May 2023Microsurgery is a foundational plastic surgery principle. However, public unawareness of microsurgery and its associated rigorous training in the United States may...
BACKGROUND
Microsurgery is a foundational plastic surgery principle. However, public unawareness of microsurgery and its associated rigorous training in the United States may contribute to current misconceptions and undervaluing of plastic and reconstructive surgeons. This study aims to characterize public knowledge of microsurgery.
METHODS
A cross-sectional survey was conducted from August to September 2021 using Amazon Mechanical Turk to assess baseline public knowledge of microsurgery. A multivariable logistic regression model was constructed to evaluate the association between baseline knowledge and demographic characteristics. Significance was set to a < 0.05.
RESULTS
A total of 516 responses were analyzed. The mean age was 36.7 years (standard deviation, 16.04 years; white, 84%; non-Hispanic, 70%). Of those surveyed, 52% agreed that general surgeons perform microsurgery, while only 28% agreed that plastic and reconstructive surgeons perform microsurgery. When asked if head and neck reconstruction, breast reconstruction, and finger replantation required microsurgery, only 28, 41, and 41% of respondents agreed, respectively. When controlled for sociodemographic factors, Hispanics had significantly more odds to mistake that head and neck reconstruction did not require microsurgery (odds ratio [OR] 95% CI 0.49; 0.30-0.80; = 0.004) and less odds to consider plastic and reconstructive surgeons for reconstruction (OR 0.51; 95% CI 0.32-0.84; = 0.008). Females had 1.63 more odds of considering plastic and reconstructive surgeons for reconstruction (95% CI 1.09-2.43; = 0.017). Low-educated participants had significantly more odds to consider general surgeons as those who performed reconstructive microsurgery (OR 8.70; 95% CI 1.09-69.40; = 0.041).
CONCLUSION
Misconceptions of microsurgery as a foundational principle of plastic surgery persist and correlate with undervaluing the specialty. Knowledge differs by ethnicity, level of education, and gender. Therefore, patient counseling should use culturally appropriate elements to demystify microsurgery, build value, and better inform risks and benefits.
Topics: Female; Humans; United States; Adult; Microsurgery; Cross-Sectional Studies; Plastic Surgery Procedures; Surgery, Plastic; Surveys and Questionnaires
PubMed: 35817402
DOI: 10.1055/a-1896-5598