Limb salvage using microsurgical free tissue transfer in severe frostbite – a retrospective case series
A Karir, E Holzer*, T Quaife, J Winter, L Sigurdson
Winnipeg, MB
Purpose: Frostbite is often managed conservatively, however, in severe cases with full- thickness tissue loss, microsurgical free tissue transfer is required for soft tissue coverage and limb salvage. Given the rarity, the techniques and outcomes of these cases are not well described. Thus, the purpose of this study is to present a single-center retrospective case series of frostbite injuries requiring microsurgical reconstruction for limb salvage.
Method: A single-center retrospective review was conducted of all patients who underwent free tissue transfer by a single surgeon from 2008 to 2022. Patients of all ages were included if they suffered a frostbite injury requiring free tissue transfer. Demographics, operative details, and surgical outcomes were recorded.
Results: Eight patients (five male, three female) with frostbite injuries were included in the study. Patients had frostbite injuries either to the lower extremities (n = 4, 50%) or to both upper and lower extremities (n = 4, 50%). Sixteen free flaps were done in total including four paired chimeric and eight single free flaps. Flap recipient sites included knees (n = 5), dorsal hands (n = 2), thumbs (n = 2), heels (n = 2), and foot (n = 1). Flap survival rate was 100%. Six (75%) patients had complications, with the most common being minor flap dehiscence (n = 3). All lower extremity reconstructions were able to weight-bear or were cleared to weight-bear at an average of 125.2 days post-injury (range 87-164). Mean follow up time was 1.4 years (range 0.3-4.2).
Conclusions: This case series demonstrates that free tissue transfer is a robust option for soft tissue coverage and functional limb salvage in patients with severe frostbite injuries to both upper and lower extremities.
Learning Objectives: Participants will be able to describe the use of microsurgical free tissue transfer for limb salvage in severe frostbite.
Consecutive microsurgical cases performed by single surgeon at a Canadian tertiary care centre: A retrospective review
J Gormley*, A Chen, O Olaiya, R Avram, C Coroneos
Hamilton, ON
Purpose: The practice of a plastic surgery trained microsurgeon varies over time with changes in clinical interests, practice standards, and the addition of other surgeons within the same catchment area. The aim of this study was to analyze consecutive microsurgical cases performed by a single surgeon during their 13- year experience at a Canadian tertiary care centre.
Methods: A retrospective chart review was performed of all free tissue transfers between 2007-2020 completed by a single surgeon. The primary outcome was the annual number of free flap cases over time. Secondary outcomes included the type of reconstruction and rate of complications.
Results: A total of 776 free flaps were performed on 530 patients. The most common type of reconstruction was breast, followed by lower extremity and head and neck. There was a significant change in the type of reconstruction cases over time (p < 0.005). There were a total of 125 postoperative complications. After adjusting for the number and type of reconstruction, there was no statistically significant impact of years in practice on rate of complications (p = 0.184). Overall, there was a 96.5% success rate for free tissue transfer. There was no association between flap failure and year in practice (p = 0.757).
Conclusion: The type and volume of free flap reconstruction has changed with the addition of new plastic surgeons in a single catchment area. However, surgical experience does not seem to have a significant positive impact on the rate of free flap complications or success. At our center, free tissue transfer remains a valuable tool for reconstruction in both low- and high-risk patients.
Learning objectives: The participant will be able to identify common complications of free tissue transfer. They will learn about common factors that impact the volume and type of reconstruction in a single surgeon's practice over time.
Identification of the anatomy of the deep temporal vein using computed tomography imaging: A retrospective cross-sectional review of patient imaging
V McKinnon*, S Riaz, E Stubbs, MH McRae, MC McRae
Hamilton, ON
Purpose: The deep temporal vein (DTV) can be used in free flap procedures when the superficial temporal vein is inadequate. Despite its potential utility, its branching patterns have only been examined in one small anatomic study. The purpose of this study was to examine computed tomography angiography (CTA) images to determine DTV location, variation, and suitability as a microvascular recipient, to provide surgeons with a guide for its use in head and neck defects.
Method: A retrospective chart review identified 152 patient CTA images (76 female; 76 male) in a single academic center imaging database, selected consecutively from January 2017 to April 2020. Reason for imaging, DTV caliber, laterality, distance to zygomatic arch (ZA [coronal and sagittal]), distance to lateral orbital rim (LOR), and branching pattern were recorded.
Results: Average caliber was 3.46 ± 1.29 mm (95% confidence interval [CI] [3.32, 3.61]; range, 1.00–10.8). Bilateral DTVs were observed in 98.7% of patients. Average distance to landmarks were as follows: ZA (coronal), 13.8 ± 5.85 mm (95% CI [13.2, 14.5]; range, 2.7–33.8); ZA (sagittal), 15.1 ± 6.12 mm (95% CI [14.1, 16.1]; range, 2.8–47.2); LOR, 47.1 ± 9.09 mm (95% CI [46.0, 48.1]; range, 10.8–62.9). Seven branching patterns were identified, including a posterior vertical variant that bypasses the superficial temporal fat pad.
Conclusions: The DTV is a “lifeboat” option for head and neck reconstruction. Its average caliber is sufficient for use in microsurgery. Knowledge of both its typical and aberrant courses allow for efficient preoperative planning and surgical dissection. CTA is a useful adjunct when planning to use the DTV for free tissue transfer.
Learning Objectives: To identify the most common location of the DTV for use in head and neck flap reconstruction. To distinguish the utility of preoperative CTA for DTV identification
Outcomes of prophylactic lymphaticovenous bypass immediately following axillary lymph node dissection
J-L, Senger*, R Skoracki, KU Park
Columbus, OH
Purpose: Lymphedema following axillary lymph node dissection (ALND) for breast cancer is identified in up to 40% of patients. Prophylactic lymphaticovenous bypass (PLVB) is a novel microsurgical technique aimed at preventing lymphedema by redirecting lymphatic flow from the cut lymphatics into a vein. This study compared volumetric measurements and patient reported outcomes measures (PROMs) of PLVB + ALND vs. ALND.
Methods: Patients who underwent ALND between 2011-2020 at our center were reviewed. Demographic (age, BMI, comorbidities) and oncologic data (adjuvant therapy, number/status of lymph nodes, surgical management of breast and lymph nodes) were noted. Primary outcomes included limb circumference measurements (finger, wrist, elbow, arm, axilla), bioimpedance scores, and perometer values. Secondary outcomes included PROMS, incidence of cellulitis, and need for subsequent lymphedema surgical management.
Results: 539 patients who underwent ALND were identified, and 373 patients were included. 93 (25%) patients underwent ALND + PLVB. Demographics and oncologic features of ALND vs. ALND + PLVB groups were comparable. Average follow-up time with physiotherapy was 23 months (1-65 months). Circumferential measurements were significantly improved among ALND + PLVB patients at the elbow (p < 0.05) and trended towards improved at the forearm (p = 0.07). There was no difference in bioimpedance or perometer values, or the incidence of postoperative cellulitis. Patient-reported outcomes identified lower incidence of achiness/heaviness/tightness/pain to the affected limb in ALND + PLVB patients (26.9%) compared with ALND patients (40%). Further, patients reported improved limb function (16.7% vs. 21.4% impairment, p = 0.05). ALND + PLVB patients (9.7%) were less likely to require therapeutic LVB than ALND patients (17.8%) in subsequent years.
Conclusions: Our results suggest PLVBs contribute to decreasing lymphedema and improve patient comfort/satisfaction and limb functionality. We advocate that PLVBs should be routinely discussed with breast cancer patients undergoing ALND. Learning points: PLVB + ALND a) improves PROMs, b) improves limb circumference measurements, and c) decreases the need for future lymphedema surgery.
DIEP flap in breast reconstruction: a morbidity study of bilateral versus unilateral reconstruction
R Laurent*, R Schoucair, MA Danino
Montréal, QC
Purpose: The DIEP flap is a modality in breast reconstruction of choice. Despite its well-documented benefits and complications, a lack of evidence remains with regards to the risks of performing a bilateral versus a unilateral reconstruction. As such, we sought to compare the rates of adverse outcomes in the perioperative and postoperative periods associated with a unilateral versus a bilateral DIEP flap breast reconstruction.
Methods: A retrospective cohort study of 178 consecutive patients undergoing unilateral versus. bilateral deep inferior epigastric perforator flap breast reconstruction was performed at our tertiary care center over a 3-year period. Data on demographics, operative time, intraoperative and postoperative complications, and surgical re-exploration, were extracted for both groups. Statistical analysis was performed on a per-flap basis.
Results: A total of 157 unilateral and 42 bilateral deep inferior epigastric perforator flaps were identified. The rate of intra-operative complications was 12.1% for unilateral versus. 4.8% for bilateral flaps (p = 0.26). Total post-operative complications rates were 30.6% for unilateral versus 54.7% for bilateral flaps (p = 0.003). Surgical re-exploration was performed in 12.7% of unilateral and 11.9% of bilateral cases (p = 0.88). The rate of total flap loss was similar between types of reconstruction, occurring in 2.5% of unilateral vs. 2.4% of bilateral flaps (p = 1).
Conclusion: This study demonstrates the rate of complications per flap is significantly higher in bilateral versus unilateral DIEP flap breast reconstruction. Bilateral DIEP breast reconstruction should be decided on a case-by-case basis.
Learning objectives: After this presentation, the learner will be able to compare the differences in morbidity between simple and double DIEP flaps. It will give scientific data to the attendees to explain to the patients the level of complications. The surgeons may reconsider the indication of bilateral DIEP flaps for some patients.
The cost-utility of neurotization in post-mastectomy breast reconstruction from the healthcare payer perspective
M Saggaf*, L Snell, J Lipa, P Pechlivanoglou, A Ghumman
Toronto, ON
Purpose: Neurotization following post-mastectomy breast reconstruction is associated with added costs and improved sensory function. However, the cost-effectiveness was not defined. The aim of this study was to assess the cost-utility of neurotization following autologous breast reconstruction compared to no neurotization from a healthcare perspective.
Methods: We used a Markov decision analysis model, accounting for postoperative complications, the probability of protective sensation, added costs and utilities. We used a half-cycle correction with a 1.5% discount rate. The time horizon was a lifetime. The key parameters in the study were derived from data from a recent systematic review. The model assumed minimal added risks of complications following neurotization and no sensory recovery in the first two years following surgery. The outcomes were defined as added Quality-Adjusted Life Years (QALYs) and the incremental cost-effectiveness ratio (ICER). We compared no neurotization to neurotization using direct coaptation.
Results: In the base case analysis, the incremental increase of QALYs was 1.7, favouring neurotization, with an added cost of $3,574. The ICER was $2100/QALY. The results were robust through a wide range of sensitivity analyses.
Conclusion: Neurotization following breast reconstruction is cost-effective, and it should be routinely offered to patients undergoing autologous breast reconstruction. Healthcare policymakers should allow neurotization to be performed during autologous breast reconstruction.
Learning Objective: The participants will understand the cost-utility of breast neurotization following breast reconstruction.
How to stay tight lipped
A Singh*, C Schrag
Calgary, AB
The use of ansa cervicalis to marginal mandibular nerve transfer in facial nerve reconstruction.
Purpose: Facial nerve reconstruction is a complex and intricate practice. Nerve transfers can provide an additional source of axons, may allow more rapid regeneration, and may decrease synkinesis. While the hypoglossal and hemi-hypoglossal nerve transfers have been used extensively in the setting of facial nerve reconstruction, there is less evidence for the use of the ansa cervicalis as a donor nerve. This procedure has not been described in North America before. In this pilot study we report the outcomes of ansa cervicalis to marginal mandibular nerve in 3 cases.
Method: We have performed ansa cervicalis to marginal mandibular nerve transfer as a stand alone procedure or more commonly as part of other techniques for facial nerve reconstruction. We assessed patients clinically and electrophysiologically to determine lower lip tone and function. Complications were assessed.
Results: Patients suffered few complications. Lower lip tone was improved.
Conclusions: The ansa cervicalis to marginal mandibular nerve transfer provides an additional option for facial reanimation.
Learning Objectives: 1. Recognize the need to improve lower lip tone and function. 2. How to perform ansa cervicalis to marginal mandibular nerve transfer. 3. To demonstrate the expected patient outcomes.
Upper extremity nerve transfers in Acute Flaccid Myelitis: the first reported Canadian experience
M Jakeman*, E Ho, A Anthony, K Davidge
Toronto, ON
Purpose: Acute Flaccid Myelitis (AFM) is a rare but devastating pediatric condition. Recovery is variable and many have residual weakness of their extremities. We present our initial experience of upper extremity nerve transfers in AFM.
Method: A retrospective review was conducted of all children who underwent upper extremity nerve transfers for AFM at our institution in 2019 and 2020. Transfers to restore shoulder and/or elbow motion were performed when recipient muscles had no signs of clinical or electrophysiologic reinnervation on serial examination, and when at least one donor nerve was available.
Results: Nerve transfers were performed in six children (4 M, 2F) on eight limbs. Mean age at disease onset was 5.8 years (range, 3.8?8.6). D68 enterovirus was detected in two cases. Three children presented with four-limb involvement; two required respiratory support. Median time from disease onset to surgery was 13 months (range, 12-19). Among the 10 shoulder nerve transfers performed, the most common were spinal accessory to suprascapular (4) and ulnar to axillary (5). Three transfers were performed for elbow flexion using median, ulnar or intercostal nerves as donors. One radial to triceps transfer was performed for elbow extension. One transfer was aborted intraoperatively owing to weak donor nerve. Median postoperative follow-up was 29 months (range, 22-30). Transfers for shoulder abduction achieved a median range of antigravity motion of 85 degrees (range, 30-155). All three patients undergoing transfers for elbow flexion achieved full antigravity motion. No donor site motor weakness was identified; transient median nerve paraesthesia was noted in one patient.
Conclusions: Nerve transfers in AFM had variable outcomes. Our results support the current literature in that restoration of motion at the elbow is more consistent than that of the shoulder.
Learning Objectives: To understand what can be achieved with upper extremity nerve transfers in AFM.
Treatment of nerve injury following cervical spine surgery with upper extremity nerve transfers: A case series
VM Doucet*, TA Clark, JL Giuffre
Winnipeg, MB
Introduction: Nerve transfers to restore or augment function following spinal cord injury is an expanding field. There is a paucity of information, however, on the use of nerve transfers for patients having undergone spine surgery. The incidence of neurologic deficit following spine surgery is rare but extremely debilitating. The purpose of this study is to describe the functional benefit following upper extremity nerve transfers in the setting of nerve injury following cervical spine surgery.
Methods: A single-center retrospective review of all patients who underwent nerve transfers following cervical spine surgery was completed. Patient demographics, injury features, spine surgery procedure, nerve conduction and electromyography study results, time to referral to nerve surgeon, time to surgery, surgical technique and number of nerve transfers performed, complications, post-operative muscle testing and subjective outcome were reviewed.
Results: Thirteen nerve transfers were performed in 6 patients following cervical spine surgery. Nerve transfer procedures consisted of a transfer between a median nerve branch of flexor digitorum superficialis into a biceps nerve branch, an ulnar nerve branch of flexor carpi ulnaris into a brachialis nerve branch, a radial nerve branch of triceps muscle into the axillary nerve and the anterior interosseous nerve into the ulnar motor nerve. Average patient age was 55 years old, all patients were male and underwent surgery on their left upper extremity. Average referral time was 7 months, average time to nerve transfer was 9 months and average follow up was 11 months. Average pre-operative muscle grading was 0.9 out of 5 and average post- operative muscle grading was 4.1 out of 5 (p value < 0.00001).
Conclusions: Upper extremity peripheral nerve transfers can significantly help patients regain function from deficits secondary to cervical spine procedures. Performing nerve transfer surgery has minimal risk to the patient by using expendable donors and minimal postoperative pain.
Learning Objectives: 1. Participants will learn about the management options for nerve injuries following cervical spine surgery. 2. Participants will learn about the indications and outcomes of upper extremity nerve transfers for the treatment of nerve injuries following cervical spine surgery. 3. Participants will takeaway the importance of collaboration with spine surgeons to improve outcomes for this patient population.
Electrophysiological evidence of hand intrinsic muscle reinnervation with median nerve axons after end-to-side or end-to-end distal anterior interosseous nerve to ulnar motor nerve transfer
X Ma*, N Habra, JC Lin
Montréal, QC
Purpose: To evaluate hand reinnervation patterns following distal anterior interosseous nerve (AIN) to ulnar motor nerve end-to-side (ETS) or end-to-end transfer (ETE) with clinical and electrophysiological data.
Method: A retrospective cohort study was done with patients having undergone AIN to ulnar nerve ETS and ETE transfer from a single centre between 2017 to 2022. Motor reinnervation of the abductor digiti minimi (ADM) by the AIN was evaluated by recording motor nerve conductions from the median nerve at the elbow to the ADM. Muscle recruitment with and without pronation was also assessed by needle EMG.
Results: A total of 16 patients were included in the study, with 12 having had ETS and 4 ETE nerve transfer. Post-operative EMGs were performed on average 17.4 months after the intervention. Nine of the 12 patients in the ETS group had undergone motor nerve conduction studies from the median nerve to ADM. Six of the nine showed positive amplitudes, ranging from 0.6 mV to 3.7 mV, while the remaining three had no evidence of conduction from the median nerve to the ADM muscle. In contrast, all four patients in the ETE group had positive motor nerve conduction from the median nerve to the ADM muscle ranging from 0.3 mV to 6.3 mV. A qualitative increase in muscle recruitment was present in all patients while pronating in the ETE group, while a similar observation was present in 37.5% of the ETS group.
Conclusions: This study shows clinical and electrophysiological evidence to support the growth of median nerve axons into muscles normally innervated by the ulnar nerve in patients with ETS as well as ETE distal AIN to ulnar motor nerve transfers.
Learning Objectives: 1) Learn about the role of EMGs following nerve transfers 2) Understand the difference between ETS and ETE nerve transfers
