Microsurgical Anastomosis Research Articles

Antithrombotic efficacy of direct oral anticoagulants on patency rate following microsurgical anastomosis in crushed rat arteries

BackgroundDuring the last decade direct oral anticoagulants (DOAC) have been established in various fields of medicine.Their use in microsurgery has not been evaluated yet though. This study aims to evaluate their efficacy in microsurgery and additionally compare them with a well established antithrombotic agent. Materials and methodsThe right femoral artery of 101 rats divided into 4 groups, was crushed and anastomosed. Group A (20 rats) received placebo therapy (1 ml NaCl 0.9%, orally), while Group B (27 rats), Group C (27 rats) and Group D (27 rats) received rivaroxaban (3 mg/kg, orally), dabigatran (30 mg/kg, orally) and enoxaparin (30 mg/kg, subcutaneously) respectively. All drugs were administered 3 h preoperatively and once daily for the following postoperative days until the sacrifice of the animals. Patency was evaluated at 1st, 7th and 20th postoperative day. Following patency evaluation the rats were sacrificed and the vessels were harvested for histological examination. ResultsNone of the rats died postoperatively. Patency rates of rivaroxaban group (78%), dabigatran group (70%) and enoxaparin group (63%) were statistically similar, but significantly higher than the placebo-treated control group (p < 0.05). Cells with morphologic features of endothelial cells were evident 7 days after the injury. ConclusionThe results of this study demonstrate the following: (1) rivaroxaban and dabigatran through inhibition of thrombus formation significantly enhanced the patency rate compared to placebo treatment (2) the antithrombotic efficacy of rivaroxaban and dabigatran in compromised microvessels was similar to that of enoxaparin, the most widely used antithrombotic agent.

Microsurgical soft tissue reconstruction in lower extremity osteitis

The aim of this study was to analyse retrospectively the pre- and intraoperative factors influencing flap loss after free flap coverage of septic skin defects caused by osteitis of the lower extremity with an anterolateral thigh flap (ALT) or latissimus dorsi (LD) flap. Twenty-seven patients were surgically treated with LD flap coverage and 45 patients with ALT flap coverage between 2004 and 2013. Their anthropometric, pre- and intraoperative parameters were investigated retrospectively. Flap survival was 81.5 % for LD flaps and 82.2 % for ALT flaps. Major complications led to a significantly higher flap loss both in LD (p = 0.01) and ALT flaps (p < 0.0001). Furthermore, there was a significant increase in flap loss with pre-existing diabetes mellitus in the LD group (p = 0.001) and with acute osteomyelitis being the underlying cause of the soft tissue defect in the ALT group (p = 0.034). Regardless of the flap's postoperative success, LD flaps were used for significantly larger soft tissue defects to be reconstructed (p = 0.001), with the duration of surgery (p < 0.0001) and cold ischaemia time (p = 0.001) being significantly longer compared with ALT flaps. The success of microsurgical flap reconstruction in lower extremities after osteitis was influenced by a low number of cases with preexisting diabetes mellitus, causative acute osteomyelitis, and major complications. Therefore, optimal management of both parameters and precise microsurgical anastomosis are prerequisites for successful plastic reconstruction of soft tissue defects.

Synchronous microsurgical anastomosis in complex replantation surgery.

We conducted a retrospective case control study of digital replantations in 16 patients from September 2015 to January 2017. Half of the patients were treated by a synchronous microsurgical technique and the other half underwent conventional micro-anastomoses. The total time for anastomoses, total operation time and survival of digits were the major endpoints in this study. The number of digits replanted and the anastomosis method had significant effects on total anastomosis time. The mean anastomosis time for each digit was 46 min and 70 min in the synchronous and conventional groups, respectively, a 34% reduction in anastomosis time in the synchronous group when compared with the conventional group. Patency rates were 87% (13/15) of all the digits replanted in each group. Level of evidence: IV.

Thumb Amputations in Children: Classification and Reconstruction by Microsurgical Toe Transfers

Traumatic amputations of the thumb are rare in children compared with adults, but hand surgeons remain reticent to consider microsurgical reconstruction with toe-to-thumb transfers. This study reports the functional outcomes and complications of children with traumatic thumb amputations who underwent toe-to-thumb reconstruction. A retrospective review of children who sustained thumb amputations and whose parents elected for their child to undergo reconstruction by toe-to-thumb transfer was performed. Details of the level of thumb amputation, whether other fingers were also amputated, which toe was transferred on which vascular pedicle, survival of the transfer, and complications, were collected. Opposition, sensation, and growth of the toe-to-thumb transfers was measured. Functional and psychosocial outcomes were evaluated by both the parents and the older children using the Pediatric Outcomes Data Collection Instrument questionnaire. Twenty-one thumb amputations in 19 children between the ages of 2 and 17 years were referred for secondary reconstruction. Ten were isolated thumb amputations and 11 were combined thumb and multiple finger amputations. Two children had bilateral thumb amputations. Twenty-one toe-to-thumb transfers were performed: 14 second toe transfers and 7 great toe transfers (3 great toe and 2 trimmed and 2 Morrison wraparound variations). There were no immediate postoperative reexplorations of the microsurgical anastomoses and all toe transfers survived completely. All children regained pinch and grasp function and sensation. There were no gait problems in the donor feet. Microsurgical toe-to-thumb transfers should be offered as an alternative option to the traditional techniques of distraction lengthening and pollicization, for posttraumatic thumb reconstruction in children for any level of amputation from just distal to the carpometacarpal joint to the interphalangeal joint. Toe-to-thumb transfer provides length, opposition, and sensation without disturbing ambulation and is associated with excellent psychosocial outcomes as evaluated by both parents and older children. Therapeutic IV.

A two-stage inversion technique for total auricular reconstruction: case report and literature review

BackgroundThe reconstruction of a total amputated auricle is aesthetically demanding for otorhinolaryngology surgeons. Although various reattachment methods have been introduced since 1898, only a few have achieved satisfactory aesthetic outcomes. This study aimed to present a successful case of auricular reconstruction using a two-stage inversion technique.Case presentationThe patient’s left ear was extensively lacerated in a violent event 3 h before admission. The first-stage surgery was performed within 6 h of ischemic time. The amputated segment was prepared and trimmed carefully, and the anterior aspect of the avulsed auricle was directly sutured. The posterior skin of the ear was separated from the cartilage to close the wound. Then, using an inversion maneuver, the cartilage was pushed into a postauricular underlying muscle bed. In the second-stage surgery 27 days after the first procedure, the auricle was released and the normal ear structure was restored using full-thickness skin grafting. During a follow-up of more than 9 years, the patient showed satisfactory postoperative results in terms of cosmetic and functional outcomes of the reattached auricle. The size of his left ear was about 90% of the size of his right ear.ConclusionsThe reconstruction of a total amputated auricle is challenging. The key to surgery lies in the sufficient preservation of the meticulous shape of the cartilage. The microsurgical anastomosis is a good choice only in selected cases. It is believed that the two-stage inversion technique can be a simple alternative to reconstruct the auricle in most situations when it is lacerated and contaminated.

A Modification of an Established Method of Intercalary Extremity Bone Defect Reconstruction: The "Hemi-Capanna" Technique.

Skeletal reconstruction of segmental defects of the appendicular skeleton is among the most challenging tasks in reconstructive surgery. A popular method of reconstruction of large osseous defects is the combination of massive allografts and vascularized bone transfer. We present and discuss our experience with a modification of the traditional Capanna technique in which the allograft is split in half longitudinally to provide for more space for postoperative fibula hypertrophy. Patients who underwent reconstruction of segmental intercalary defects of the tibia using our modified technique were retrospectively identified. The following parameters were retrieved: patient age, race, sex, length of skeletal defect, recipient vessels, type of microsurgical anastomosis, union rate, complication rate, ambulation (yes/no), and follow-up (in months). Two male patients underwent reconstruction of the tibia via the modified "hemi-Capanna" technique. The tibia defect measured 12 and 13 cm, respectively. No intraoperative or postoperative complications were encountered. Osseous union was obtained in both patients who are both ambulatory. The hemi-Capanna technique not only leaves more room for hypertrophy of the vascularized fibula, but also simplifies the technique of combining an allograft with vascularized bone transfer in reconstructions of segmental skeletal defects of the appendicular skeleton.

Implications of Internal Mammary Lymph Node Sampling During Microsurgical Breast Reconstruction.

Internal mammary lymph node (IMN) chain assessment for breast cancer is controversial; however, current oncologic data have shed new light on its importance. Metastatic involvement of the IMN chain has implications for staging, prognosis, treatment, and survival. Here, we analyzed our data gathered during sampling of the IMN and the oncologic treatment changes that resulted from our findings. A retrospective chart review was performed on 581 patients who underwent free-flap breast reconstruction performed by the senior author. All dissected IMNs were submitted for pathological examination. Patient demographics, oncologic data, and the results of IMN sampling were reviewed. 581 patients undergoing 981 free flaps were identified. A total of 400 lymph node basins were harvested from 273 patients. Of these, nine had positive IMNs. Two of these nine patients had positive IMNs of the contralateral nonaffected breast. Five patients had positive axillary lymph nodes. Four patients had multifocal tumors, one of which was bilateral. Seven patients had an increase in cancer stage as a result of having positive IMNs. Six patients had a change in treatment: two patients required additional chemotherapy, one received adjuvant radiation therapy, and three necessitated both supplemental chemotherapy and radiation. Opportunistic biopsy of the IMN while dissecting the recipient vessels is simple and results in no added morbidity. We recommend that biopsy of the IMN chain be performed whenever internal mammary vessels are dissected for microsurgical anastomosis in breast cancer patients. Positive IMN involvement should encourage thorough oncological workup and treatment reevaluation. Case series.

Pyloric Artery to Segment 4 Artery Vascular Reconstruction, a Novel Surgical Technique Developed for Donor Safety after LLS Hepatectomy, and now Proposed for Extended Right Lobe Split Grafts

Introduction Strategies to increase the pull of organs include the use of segmental liver grafts. While performing left lateral segment (LLS) from a living donor, the transection of the left hepatic artery becomes critical when a dominant segment 4 artery (S4A) emerges higher from the main right and left bifurcation. Similar situation occurs while performing split procedures. In the living donor, it is mandatory to assure donor safety, while when using extended right lobe split grafts (ERLSG) an adequate arterial supply to segment 4 (S4) will reduce post-operative recipient morbidity. Aim We aim to describe a novel technique consisting on performing a pyloric to segment 4 arterial microsurgical reconstruction. Report of cases 1) A LLS 45 year old living donor was selected for a paediatric recipient, during the procedure a high dominant S4A was dissected, and in order to obtain an appropriate left HA length and diameter for the recipient, it was necessary to section it. Once the graft was removed from the field and in order to guarantee donor safety, the pyloric artery was dissected with a sufficient length to rotate it, and to perform a microsurgical anastomosis to the S4A.After reperfusion, the S4 recovered color and Doppler signal.Reconstruction remains opened by CT scan angiogram 40 months after the procedure. 2) Similarly, during an ERLSG cadaveric LTx done in a 61 yrs old, HCV pt with HCC within Milan criteria, the S4A was found to be transected during the split procedure. After performing the portal and HAT reconstruction, the S4 remained incompletely perfused, therefore, the piloryc to S4A reconstruction allowed to recover color and Doppler signal.Reconstruction remains open by CT scan angiogram 3 months after the procedure.No biliary, or cut surface complications were seen in both casesConclusions The described procedure it is a simple and novel technique that can be used for LLS and ERLSG. Its use might contribute to increase donor selection, and to reduce living donor and recipient S4 related complications.

573 Effectiveness and safety of microsurgical varicocelectomy for treating nutcracker phenomenon associated varicocele

The aim of our study was to access the clinical effectiveness and safety of microsurgical varicocelectomy in the treatment of male nutcracker phenomenon associated varicocele. We retrospectively analyzed 66 patients with varicocele in our institution between August 2015 and February 2017. Patients were categorized into two groups. In group 1, 35 patients with nutcracker phenomenon associated varicocele were included. Furthermore, 25 patients underwent microsurgical varicocelectomy were classified as group 1A, and the rest 10 patients underwent microsurgical spermatic-inferior epigastric vein anastomosis were classified as group 1B. Group 2 included 31 patients with varicocele alone underwent microsurgical varicocelectomy. The preoperative serum hormone levels (E2, FSH, LH, PRL), results of scrotal ultrasound and semen analysis between group 1 and group 2 were observed no significant difference except in age, BMI, T level and peak velocity ratio. There was no significant difference in preoperative value between group 1A and group 1B. However, group 1A spent less surgical time compared with group 1B (p<0.001). Significant decreases in post-operative left internal spermatic vein diameter and the reflux time without the Valsalva maneuver were observed compared with preoperative among group 1A, 1B and 2, respectively. In addition, semen parameters significantly improved at 6 months postoperatively compared with preoperative among group 1A and 1B. But, the postoperative parameters like the results of scrotal ultrasound and semen analysis showed no statistically different among group 1A, 1B and 2.

Application of Delayed Surgical Managements in Patients with Stensen's Duct Injury

The study aimed to retrospectively evaluate surgical treatment outcomes after delayed parotid gland and duct injuries. Nine patients subjected to parotid gland and duct injuries with 1- to 3-month treatment delay were retrospectively evaluated with special reference of etiology, past medical history, and injury location. Conservative treatment, microsurgical anastomosis, and diversion of salivary flow or ligation were chosen for delayed parotid gland and duct injuries concerning to their site of injury, time of repair and procedures. Assistant treatment as pressure dressing was adopted thereafter. All patients experienced an uneventful recovery at the time of finalizing the study. Two patients received Stensen's duct ligation, 5 received microsurgical anastomosis and 2 accepted salivary flow diversion for 5 patients with sialoceles and 4 patients with fistulas, and no re-occurrence was found. Facial paralysis occurred after surgery in 4 patients, and 3 of them recovered after the nerve nutrition treatment. Our study suggested that appropriate surgical treatment is efficient for the re-establishment of the tissue function and facial aesthetic for delayed injury of the parotid and its duct.

Mesoappendix as potential donor site for vascularized lymph node transfer: anatomic study

BackgroundThe standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a “spare part,” may be an ideal autologous lymph node transfer donor site. MethodsIn this Institutional Review Board–approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length. ResultsA single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively. ConclusionsThe mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.

A novel microsurgical anastomosis training model using gradually thawed cryopreserved microvessels of rat cadavers

In consideration of the 3-R-rule (Refine-Replace-Reduce) as a guideline for promoting ethical use of animals for surgical training, we present a novel training model for microvessel anastomosis. In a rat cadaveric study, we evaluated the surgical anatomy of the common carotid artery (CCA), external jugular vein (EJV) and femoral vessels (FV) which were then used as templates for the present investigation. Anatomical dissection of 30 rat cadavers was performed. Two residents without prior microsurgical experience were included in the study and performed 5 CCA, 5 femoral artery, 5 EJV and 5 femoral vein anastomoses. Patency and leakage served as qualitative variables and operation time as a quantitative variable for efficiency control. The average time improved for arterial and venous anastomoses (45 min–22 and 60 to 32 min, respectively) for both surgeons. While both surgeons experienced patency failure or leakage within the first half of performed arterial and venous anastomoses, they could improve to a 100% patency rate without the occurrence of leakage for the last half of trials. The rat head & neck anatomy presents various characteristics related to the harvest of the vessels of interest. We provide anatomical knowledge about the topography related to the harvest of the CCA, EJV, and FV. Our model is an easily accessible, low-cost microsurgical simulation model, allowing a realistic and instructive performance of anastomoses. Since cadaveric vessels are used, an approval of the local ethics committee is not needed.

"Moneyball" Comes to Replantation: How We Assess Our Work: Commentary on an article by Hongyi Zhu, MD, et al.: "Patency Test of Vascular Anastomosis with Assistance of High-Speed Video Recording in Digit Replantation".

Commentary In the 50-plus years of replantation surgery, the “strip test” has been the universal, manual observational test of vessel patency. All other downstream evaluations with pulse oximetry, ultrasonic flow metering, laser Doppler scanning, and/or capillary refill testing are preceded by, and predicated on, a successful strip test of the vessel. A successful test denotes appropriate directional flow through the repair. Patency of the repair is the near-term outcome sought by the surgeon who creates a microvascular anastomosis with the operating microscope. Modern dual-head, binocular operating microscopes are equipped with electronic controls for 2-axis motion, focus, light intensity, and video monitoring with high-definition video cameras that can grab single freeze-frames of images. Experienced surgeons can look at a microsurgical anastomosis of either vein or artery and evaluate the quality and dimension of the repair. Once happy with the coaptation of vessel walls, the spacing of the sutures, and the parallel nature of the lumens both upstream and downstream, they are then ready for the next functional test. The strip test is that functional test and requires an experienced eye to judge the speed and volume of blood with which the deflated vessel fills. The surgeon’s overall perception or gestalt of the repair can be tempered or even impaired by unseen biases that shape the surgical experience. The number of times the repair was revised, the hour of the night, the third digit being replanted rather than the first, or the level of expertise of the assistant or the surgical technician can alter the overall judgment of the quality of the test. In the 2003 book Moneyball: The Art of Winning an Unfair Game, Michael Lewis described new analytical methods used in baseball to quantify what experienced scouts, coaches, and pundits were subjectively observing1. Zhu and colleagues have applied a similar quantifiable approach to the strip test to predict outcome. They used an off-the-shelf, consumer-grade, high-speed digital camera with close-up lenses to concurrently capture their observations. In real time, they applied a numeric value to what was previously the subjective judgment of the surgeon in declaring a vessel suitable for adequate flow to keep the replant viable. The strip test is not without its risk. The applied pressure can damage the intima of the vessel and should be kept to a minimum. The authors’ method of evaluation took me <1 hour to prepare following their text. I used the same camera, which I already possessed and was familiar with. I tested the method using a microscope and a fluid-filled tube. They developed the idea and set out to use it in a busy clinical practice of replantation. They created a model that gave some prediction as to whether or not they and their patient would enjoy a good result. Once a certain threshold during collection in the repaired vessels had been reached in the strip test, they could stop repairing and move to the next phase of the surgery. With replants there is much to accomplish. Being sure of the quality of the strip test is time well spent. Microscopic robotics have yet to be proven of value in the mainstream of replantation procedures. However, we now have a reliable microscopic, visual assessment tool to measure our work in a consistent fashion. Better patient outcomes will hopefully prevail, as the universally applied strip test has a quantifiable and visually measurable result in digit replantation. This evaluation paves the way for a more standard comparison of surgeons and their repairs. Late at night and far into the case, it is a reasonable end point to achieve. Electronically assisted microsurgery is starting with a high-speed digital video assessment of surgical repair.

Perforator Propeller Flaps for the Coverage of Middle and Distal Leg Soft-tissue Defects.

Background:Local propeller flaps preserve the main vascular arteries of the lower extremity and muscle function, avoiding the need for a microsurgical anastomosis and the benefit of providing a “like with like” coverage. Our goal in this study was to demonstrate the versatility, safety, and complications of the local propeller flaps for lower extremity reconstruction.Methods:We present a series of 28 patients in whom we used local propeller flaps to restore small-to-medium soft-tissue defects of the lower limb in different hospitals of Managua, Nicaragua.Results:Flap average dimensions were of 48 cm2. Flap rotation was performed in 180 degrees in 85% of the cases. The propeller flaps were based on a single perforator, from the posterior tibial artery in 50%, anterior tibial artery in 39.3%, and peroneal artery in 10.7% of the cases. Complications occurred in 14% of the propeller flaps performed, with 3 partial necrosis of less than 15% of the flap transposed. Complications of the patients occurred in both sex groups; however, for the female group, there was a 75% of complications with a tendency toward statistical significance of P = 0.038. Donor site of the flap was closed primarily in 85.7% (24) of the cases.Conclusions:In our opinion, the availability and safety of local propeller flaps, justifies its use in cases where microsurgical techniques are not an option for the reconstruction of the middle and distal extremity, in small-to-medium defects of soft-tissue coverage of the lower limb.

A Prospective Evaluation of Health-Related Quality of Life following Lymphaticovenular Anastomosis for Upper and Lower Extremities Lymphedema.

Lymphedema is a progressive disease that negatively affects body image and physical, psychological, and social functions. There is lack of evidence in the present literature about the impact of super microsurgical lymphaticovenular anastomosis (LVA) on health-related quality of life (HRQoL). The aim of this prospective study is to report the outcomes of patients' HRQoL after LVA for lower and upper extremities lymphedema. Between September 2015 and February 2017, 74 patients with upper or lower limb lymphedema (ULL or LLL) underwent LVA at our center. Quality of life (QoL) was assessed by lymphedema QoL questionnaire (LyMQoL), which is a validated disease-specific instrument to measure the impact of lymphedema on patient's lives, covering four domains: function, body image, symptoms, and mood. All patients were evaluated preoperatively, 1 month after surgery, and every 3 months up to 1 year. Additionally, we evaluated the episodes of lymphangitis and the need for conservative therapy before and after surgery. After a mean follow-up of 8.5 months (range: 2-21 months), we observed an increase of 2.3 points in the overall QoL average for upper limb and 2.6 points for lower limb (p < 0.001). A statistically significant improvement in all four domains (p < 0.01) was reported after surgery, being present from the first postoperative months for both upper and lower extremities. Our study shows that lymphaticovenular anastomosis improves HRQoL in patients affected by ULL and LLL. Additionally, both a reduction of episodes of lymphangitis and a decrease in the need of conservative therapy were observed in this cohort of patients.

Technical Nuances of Exposing Rat Common Carotid Arteries for Practicing Microsurgical Anastomosis

Animal models are commonly used in training protocols for microsurgical vascular anastomosis. Rat common carotid arteries (CCAs) are frequently used for this purpose. Much attention has been paid to the technical details of various anastomosis configurations using these arteries. However, technical nuances of exposing rat CCAs have been understudied. The purpose of this study is to describe nuances of technique for safely and efficiently exposing rat CCAs in preparation for a vascular anastomosis. Bilateral CCAs were exposed and prepared for anastomosis in 10 anesthetized Sprague-Dawley rats through a midline cervical incision. The exposed length of the CCA was measured. Additionally, technical nuances of exposure and surgically relevant anatomic details were recorded. The CCAs were exposed from the sternoclavicular joint to their bifurcation (average length, 19.1 ± 2.8 mm). Tenets important for a safe and efficient exposure of the CCAs included 1) generous subcutaneous dissection to expose the external jugular veins (EJVs), 2) avoiding injury to or compression of the EJVs, 3) superior mobilization of the salivary glands, 4) division of internal jugular veins, 5) opening the carotid sheath at its midlevel and from medial to lateral, and 6) avoiding injury to the vagus nerve or sympathetic trunk. Using the principles introduced in this study, trainees may safely and efficiently expose rat CCAs in preparation for a bypass.

Anatomy of medial plantar superficial branch artery perforators: Facilitation of medial plantar superficial branch artery perforator (MPAP) flap harvesting and design for finger pulp reconstruction.

Medial plantar artery perforator (MPAP) flap was proposed as proper option for finger pulp reconstruction. To provide the previously unavailable vessel information required for this small flap design, this study aimed to gather all necessary anatomy of MPA, MPAP, and their territories of blood supply to apply in clinical MPAP flap reconstruction minimizing perforator injury. Dissection of 30 Thai cadaveric feet for visualizing superficial branch of MPA and its perforators (MPAP) using acrylic dye cannulation were performed. Diameter, length, number of branches, course, distributing areas of these vessels, and also their areas of blood supply were recorded in relation to specified landmarks, eg, C-MTH line; medial calcaneal tuberosity to plantar side of the first metatarsal head and S point; emerging point of superficial branch of MPA from deep fasciae into subcutaneous layer. Average diameter of MPA at its origin and total length are 1.63 ± 0.3 and 52.8 ± 16.1 mm, respectively. It provides 1-3 perforators, with an average size and length of 0.36 ± 0.11 and 23.2 ± 5.47 mm, respectively. Its distribution is mostly in the posteromedial quadrant within 50 and 30 mm from the midpoint of C-MTH line and the S point, respectively. The estimated perforator flap area is 2.5 cm × 1.5 cm and 4.5 cm × 2.5 cm for single and double perforators, respectively. MPAP flap was proved as another ideal option for finger pulp reconstruction. Its limitation is small size of perforators but this can be overcome by using MPA for microsurgical anastomosis instead.

Considerações Técnicas no Treinamento de Anastomoses Microvasculares em Laboratório de Microcirurgia

Anastomoses microvasculares são um procedimento cirúrgico complexo e um armamento essencial utilizado em diversas subespecialidades. A primeira etapa de treinamento em anastomose microcirúrgica deve ser sempre no laboratório. Este artigo é uma revisão sobre os fatores envolvidos no para a realização de anastomoses microvasculares. Instrumental cirúrgico, microscópio, estrutura do laboratório, procedimentos cirúrgicos, questões éticas e parâmetros radiológicos e histológicos são discutidos.

Pedicled Flaps for Reconstruction of Head and Neck Region

There has been a consistent increase in the number of publications on pedicled flaps for the reconstruction of post ablation defects in the oropharyngeal area. In principle, tissue is lifted from a donor site and moved to a recipient site without disruption of blood supply. The donor site is an exact anatomically defined region of tissue that is capable of sustaining its own blood supply. The benefits of pedicled flaps include lower technical demands that obviate the need for microsurgical anastomosis and shorter operating times. For this reason, they are mostly indicated in elderly and at risk patients. The aim of this paper is to describe our experience with the regional (pedicled) (submental, supraclavicular) flaps with a focus on reliability, function, cosmesis, donor site morbidity, and oncological safety. Reconstructive techniques using distal flaps are described in 12 patients. A submental flap for reconstruction was used in 7 patients. In 5 patients, we used the supraclavicular flap. A total of 9 patients were treated primarily for squamous cell carcinoma of the orofacial region, and 3 for low-grade adenocarcinoma of the small salivary gland. In 5 patients, there was successful engraftment of the submental flap. Ischemia and necrosis of the edges of the flap occurred in 1 case. In one patient, the 3rd day after surgery, the flap was almost totally necrotised. The supraclavicular flap in 4 patiets healed completely, 1 time during the postoperative period it was infected with partial loss of the outer part of the flap from the pre auricular region. In one case there was necrosis of the terminal part of the flap in the reconstructed part of the tongue, the defect was healed by granulation tissue. In all patients, after reconstruction using supraclavicular and submental flaps, the donor site closed primarily with minimal morbidity. Regional (pedicled) flaps are thin, and pliable with good cosmetic and functional results. Reconstruction using these flaps can be accomplished in one-stage with minimum morbidity of the donor site.Key words: pedicled flap - surgical flap - head and neck cancersSubmitted: 11. 5. 2017Accepted: 5. 11. 2017 The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.

Microsurgical anastomosis of renal vasculature in rats: A practical platform for acellular kidney transplantation

End-stage renal disease is becoming a contemporary global concern with increasing prevalence. The available treatment strategies are limited to dialysis and renal transplantation. However, limited organ supply and autoimmune rejection are the shortcomings that limit widespread application of transplantation. Favorably, regenerative medicine is able to provide acellular natural scaffolds for renal transplantation. Experimental surgeries in animal models are a fundamental step in transplantation research. This video presents a practical method for transplantation of bilateral acellular kidneys in a rat model, which could serve as a key step for further research.