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Background: Traditional microvascular anastomosis can be timeconsuming, which raises the risk of thrombosis. Damage to the endothelium during the process triggers a repair mechanism that involves platelet aggregation, smooth muscle cell proliferation, and thickening of the endothelium. Microvascular anastomosis plays a vital role in free flap transfers and replantation surgeries. Although standard suturing remains the preferred technique, it presents challenges due to its technical difficulty, extended duration, and potential for vessel wall trauma. Fibrin glue, derived from a combination of autologous cryoprecipitate and thrombin, was originally introduced for peripheral nerve repair in humans. The success of these early uses led to its expanded application in areas such as wound closure, skin grafting, and osteotomy healing. This study aims to evaluate the effectiveness of fibrin adhesive in addressing these challenges within the context of microvascular anastomosis. Methods: This experimental study included 22 male Sprague-Dawley albino rats, the rats were divided into two groups Group (1): Experimental group, we used 4 core sutures with 9/0 polypropylene placed 90 degrees from each other and 0.1 ml of fibrin glue at site of anastomosis. Group (2): As a control group we used the standard repair technique of the transected artery by 5-8 primary sutures with 9/0 polypropylene. Results: The use of fibrin adhesive significantly decreased both the number of sutures required and the time needed to complete the anastomosis. The immediate and long-term patency rates were not adversely affected by the application of fibrin glue. Histological analysis of the anastomosed vessels revealed no significant differences between the two techniques. Conclusions: In conclusion, the application of fibrin adhesive did not produce any adverse effects in microvascular anastomosis. The authors advocate for using fibrin adhesive in clinical settings, particularly in more complex cases where multiple microvascular anastomoses are necessary. [ABSTRACT FROM AUTHOR]

Background: The multiple-U technique is a new method for microvascular anastomosis that allows for easy and stable intima-to-intima contact, which is crucial for a successful procedure. The present work aimed to compare the Multiple-U technique and the simple interrupted suture technique regarding patency, time needed for anastomosis, duration of bleeding after declamping, and blood leakage. Methods: In an experimental study, forty adult male albino rats with an average weight of 200-350 gm were subjected to femoral artery anastomosis and were split into two equal groups (n = 20): simple interrupted suture in one group and multiple-U technique in another group. The milking test was done to assess the patency of the repaired vessel after an anastomosis. Anastomosis time, anastomotic leakage, bleeding time, and vessel diameter were assessed. Results: Regarding anastomotic leakage, the Multiple-U technique leakage (6-18 ml) was less than the leakage of the Simple Interrupted Suture technique (7.5-24 ml). Regarding vessel diameter after anastomosis, there was a significant decrease in vessel diameter in the simple interrupted suture technique (1.7 - 1.9 mm) when compared with the multiple U technique (1.9 - 2.17 mm) (p = 0.017). Our results showed non-significant differences between the two techniques regarding patency rate and anastomosis time. Conclusion: The multiple-U technique significantly decreased bleeding time and vessel diameter after anastomosis. Therefore, our recommendation is to use the multiple-U technique, particularly in digital replantation and in cases with a high risk of vessel occlusion. [ABSTRACT FROM AUTHOR]

The optimal sequence of microvascular clamping during free flap transfer is yet to be established. Many surgeons are reluctant to perform temporary declamping and subsequent reclamping during microvascular anastomosis; however, we generally anastomose the artery first and temporarily declamp it before performing venous anastomosis to confirm arterial patency and ensure proper alignment of the flap veins. Herein, we aimed to retrospectively investigate the efficacy and safety of this temporary revascularization method in 126 patients who underwent microvascular head and neck reconstruction. A total of 127 free flaps were transferred, with the anterolateral thigh flap (49 flaps) being the most frequently used. The internal jugular vein was the most frequently used recipient vein and end-to-side anastomoses to it were performed in 112 patients. Intraoperative reanastomosis was required because of arterial thrombosis in 5 cases (4.0%), arterial and venous thrombosis in 1 case (0.8%), injury to the flap artery distal to the anastomotic site in 1 case (0.8%), and venous twisting in 1 case (0.8%). Postoperatively, all the flaps survived without microvascular compromise. Vascular kinking or twisting of the vascular pedicle is a major cause of free flap failure. However, it is difficult to place empty vessels accurately during clamping. Nonetheless, temporary revascularization engorges the flap vein before venous anastomosis and minimizes the risk of venous kinking and twisting. According to our results, reclamping did not increase the risk of arterial thrombosis. [ABSTRACT FROM AUTHOR]

Introduction: Effective vascular anastomosis is crucial for successful hand surgery, particularly in traumatic injuries where rapid restoration of blood flow is essential. The Synovis microvascular anastomotic coupler system presents a novel approach by potentially offering faster and more reliable outcomes than traditional suturing methods. This study was conducted to assess the effectiveness and safety of the Synovis coupler for microvascular anastomoses in the wrist, evaluating anastomosis time, patency rates, and complication rates. Methods: This retrospective study examined 25 microvascular anastomoses (22 arteries and 3 veins) in 24 patients at a major trauma center. The primary outcomes measured were anastomosis time and vascular patency, which were assessed immediately post-operation and at subsequent follow-ups. Results: The average time required for anastomosis using the coupler was 7.3 min. Immediate post-operative vascular patency was 100%, with a long-term patency rate of 88%. Complications included arterial narrowing at the coupler site in 3 arteries, and complete occlusion in 3 arteries, accounting for a 12% long-term complication rate. Conclusion: Although the Synovis coupler demonstrated a significant reduction in anastomosis time and high patency rates, our data suggest that its effectiveness is more pronounced in venous anastomoses. The higher complication rates in arterial anastomoses warrant cautious use in these cases. Further research, including prospective randomized controlled trials, is needed to validate these findings and optimize patient selection criteria for using couplers in microvascular surgery.

Background: The surgical treatment of lymphedema has seen advancements in recent years, with supramicrosurgical lymphaticovenular anastomosis (sLVA) gaining global acceptance. The integration of 3D exoscopes into microsurgery offers potential ergonomic and educational benefits. However, systematic evaluation of their efficacy in sLVA remains limited. Methods: A retrospective cross-sectional study was conducted comparing the use of 3D exoscopes to conventional operating microscopes (OM) in sLVA surgeries. Patient data from January 2019 to January 2024 were reviewed, with demographic, clinical, and surgical outcome variables analyzed. Ergonomic assessments were performed using Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA), while surgeon satisfaction was evaluated through the Microsurgical Intraoperative Satisfaction and Comfort questionnaire (MISCq). Results: An analysis of 25 patients (OM group: n = 14; exoscope group: n = 11) revealed no significant differences in age, sex, etiology, or surgical site between the two groups. Surgical time, number of incisions, and number of anastomoses showed nonsignificant variations between the OM and exoscope groups. Ergonomic assessments indicated potential benefits with exoscope use, particularly for the assistant surgeon. Survey results demonstrated comparable levels of surgeon satisfaction with both instruments, with no significant differences in image quality, contrast, illumination, magnification, visual field, ergonomic maintenance, or stereoscopic orientation. Conclusions: The study suggests that 3D exoscopes are a valuable tool for sLVA supermicrosurgery, offering comparable outcomes to traditional microscopes with potential ergonomic advantages. Their integration into microsurgical practice may contribute to improved surgical comfort and team performance. Further research is warranted to confirm these findings and explore additional factors such as cost-effectiveness and long-term patient outcomes. [ABSTRACT FROM AUTHOR]

Microanastomosis presents a challenge in neurosurgical procedures, requiring specialized skills. Regular practice outside the operating room is crucial. This study aims to provide a detailed description of the side-to-side anastomosis technique and analyze its advantages in preventing failures compared with other variations. We examined the technique, characteristics, and outcomes of side-to-side bypass procedures for complex aneurysms in the anterior cerebral artery territory at our institution over the past decade. We compared our technique with those described in the literature by other groups. The Far East Neurosurgical Institute (FENI) technique was used in 15 patients, with 17 side-to-side anastomoses performed. The average anastomosis time was 27.5 minutes, with 100% patency in follow-up. Our technique demonstrated safety and effectiveness in treating intracranial aneurysms, yielding satisfactory short- and long-term functionality outcomes. We highlight the importance of maintaining a curvilinear arteriotomy shape, at least 3 times the diameter of the artery, and utilizing an interrupted suturing technique on the anterior wall. This paper presents the first comprehensive description of the side-to-side anastomosis technique, supported with images and videos for training and replicability. Our technique enhances flow dynamics and reduces the risk of acute thrombus formation. Training in simulators and microsurgery practice centers outside the operating room is essential for acquiring and refining microsurgical skills. [ABSTRACT FROM AUTHOR]

Major gastrointestinal surgical resections and subsequent reconstruction can occasionally need arterial or venous resection, can encounter variant anatomy, or may lead to injury to vessels. These can lead to arterial and/or venous insufficiency of viscera like the stomach, liver, colon, or spleen. Left unaddressed, these can lead to, partial or total, organ ischemia or necrosis. This can trigger a cascade of systemic clinical complications resulting in significant morbidity or even mortality. The aim of this case series is to highlight the utility of microvascular plastic surgical principles and practices in countering these vascular insufficiencies in emergency situations. Retrospective analysis of consecutive cases from March 2014 to May 2022, where intervention for emergency salvage of viscera was done. Microvascular surgical intervention for the vascular insufficient organ was performed, either by primary repair of vessels, use of interposition vein grafts, or anastomosis to a new source vessel (supercharging/super-drainage). Patients were monitored postoperatively for any signs of necrosis of viscera. Microvascular intervention was done in 21 cases: seven cases of supercharging of the gastric tube following esophagectomy, two cases of stomach salvage following pylorus-preserving pancreatoduodectomy, eight cases of hepatic artery restoration, two cases of splenic artery repair, and one each of colon salvage during coloplasty, etc. We were able to salvage the viscera of 20 cases. Arterial and venous insufficiencies can be predictably and safely reversed by precise microvascular techniques. Potentially, many greater numbers of patients can benefit from a microvascular approach to complex resections, injury, and viscera salvage. [ABSTRACT FROM AUTHOR]

Microscopic and ultramicroscopic vascular sutures are indispensable in surgical procedures such as arm transplantation and finger reattachment. The state of the blood vessels after suturing, which may feature vascular patency, narrowness, and blockage, determines the success rate of the operation. If we can take advantage of the golden window of opportunity after blood vessel suture and before muscle tissue suture to achieve an accurate and objective assessment of blood vessel status, this will not only reduce medical costs but will also offer social benefits. Doppler optical coherence tomography enables the high-speed, high-resolution imaging of biological tissues, especially microscopic and ultramicroscopic blood vessels. By using Doppler optical coherence tomography to image the sutured blood vessels, a three-dimensional structure of the blood vessels and blood flow information can be obtained. By extracting the contour of the blood vessel wall and the contour of the blood flow area, the three-dimensional shape of the blood vessel can be reconstructed in three dimensions, providing parameter support for the assessment of blood vessel status. In this work, we propose a neural network-based multi-classification deep learning model that can automatically and simultaneously extract blood vessel boundaries from Doppler OCT vessel intensity images and the contours of blood flow regions from corresponding Doppler OCT vessel phase images. Compared to the traditional random walk segmentation algorithm and cascade neural network method, the proposed model can produce the vessel boundary from the intensity image and the lumen area boundary from the corresponding phase image simultaneously, achieving an average testing segmentation accuracy of 0.967 and taking, on average, 0.63 s. This method can realize system integration more easily and has great potential for clinical evaluations. It is expected to be applied to the evaluation of microscopic and ultramicroscopic vascular status in microvascular anastomosis. [ABSTRACT FROM AUTHOR]

Good visualization is a prerequisite for performing microvascular anastomosis. The most commonly used dye, methylene blue, has several limitations: it is washed off quickly and stains all the vessel layers. The objective of our study is to use 2 new novel dyes for improving visualization. After ethical committee approval, 2 Dyes (2% cresyl violet, 1% eosin) were studied in 3 groups, 20 rats in each group and 5 rats in the combined group. End-to-side anastomosis was performed in the classic fashion in 45 rats. After venotomy, the dye was applied to the raw surface of the vessels and subsequently, anastomosis was performed. The improvement in visualization was judged by 3 blinded experts and nonexperts in 4 groups on a scale of 1–10. Scores were statistically analyzed. After 2 weeks, animals were re-explored to check the delayed patency, and segments were harvested for histopathologic analysis. The immediate and delayed patency rates were 100% (45/45) and 97% (33/34), respectively. In statistical analysis, the combined group (P = 0.005)was judged statistically significant because of the contrast in color. All the layers were stained by both dyes, staining lasted until the end of the surgery. Visibility of the cut ends was better in cresyl violet. All histopathologic findings suggested normal changes at the anastomotic site. This study showed that the use of these 2 dyes was not only feasible but highly efficacious. Even though all the layers were stained by both the dyes, the visibility of the cut ends was better. In both dyes, staining lasted until the end of surgery. To the best of our knowledge, this is the first study that has used these 2 novel dyes to improve visualization in microvascular anastomosis in an experimental setting. [ABSTRACT FROM AUTHOR]

Surgery under magnification with the use of the operating microscope has seen great advances, and numerous surgical procedures today depend on optical magnification. Training (to impart basic skills) in microsurgery is particularly essential to enable surgeons to take their place in the surgical team and learn further as they progressively observe, assist, and in time, perform microsurgical procedures. Various materials and models are used and have been objectively assessed and validated for simulation in microsurgical training. One such model, the live animal model (with all its disadvantages), has been the “gold standard” for simulation in microsurgical training. We have identified and put into use a new tissue model for training in microvascular surgery – the chicken mesentery, which will offer a good practical solution where the live animal model is unavailable. Further studies using this model for training at various centers will be required for validation and comparison of this tool against existing methods.

Background: This prospective randomized study evaluates surgical outcomes of head and neck free tissue transfer surgery performed by a single head and neck reconstructive surgeon comparing the use of surgical loupes and the operating microscope. Methods: Cases using surgical loupes were performed under ×3.5 magnification, whereas cases using the microscope were done using the standard operating microscope. Patient demographics, comorbidities, operative details, surgical outcomes, and flap failure were assessed. Results: Eighty‐five free tissue transfer surgeries were included. Of these, 51.8% (n = 44) free tissue transfers were performed using loupe magnification and 48.2% (n = 41) were performed using the operating microscope. Total cases requiring intraoperative microvascular anastomosis revision was 12 (15.4%)—of these, 41.7% (n = 5) were originally performed with surgical loupes and 58.3% (n = 7) were with microscope (p = 0.24). Conclusion: The current study provides novel, prospective data regarding a single head and neck reconstructive surgeon's experience at a single academic institution. From this, surgical loupes or the operating microscope can be used to perform head and neck microvascular reconstruction with no significant difference in rates of free tissue transfer failure or perioperative complications or outcomes. [ABSTRACT FROM AUTHOR]

Background The use of tourniquets and their role in extremity-based microsurgery has not been thoroughly investigated. The purpose of this study was to investigate tourniquet use and its associated outcomes and complications. The authors hypothesize that tourniquets enhance visualization, bloodless approaches to vessel harvest, flap elevation, and anastomosis without added complications. Methods A retrospective chart review was completed for patients who had undergone extremity-based microsurgery with the use of a tourniquet between January 2018 and February 2022 at two large academic institutions. Demographic characteristics, initial reasons for surgery, complications, and outcomes were recorded. Patients were separated into groups based on tourniquet use during three operative segments: (1) flap elevation, (2) vessel harvest, and (3) microvascular anastomosis. An internal comparison of complication rate was performed between cases for which a tourniquet was used for one operative segment to all cases in which it was not used for the same operative segment. Univariate and multivariate statistical analyses were performed to identify statistically significant results. Results A total of 99 patients (106 surgeries) were included in this study across sites. The mean age was 41.2 years and 67.7% of the patients were male. The most common reason for microsurgical reconstruction was trauma (50.5%). The need for an additional unplanned surgery was the most common surgical complication (16%). A total of 70, 61, and 32% of procedures used a tourniquet for flap elevation, vessel harvest, and for anastomosis, respectively. Statistical analyses identified no difference in complication rates for procedures for which a tourniquet was or was not used for interventions. Conclusion Based on these results, the authors state that tourniquets can be utilized for extremity-based microsurgery to enable bloodless dissection without the concern of increased complication rates. [ABSTRACT FROM AUTHOR]

Background The transverse cervical artery is less commonly used than other external carotid arteries as a recipient vessel. Therefore, we aimed to compare the utility of the transverse cervical artery as a recipient vessel with that of the external carotid artery system for microvascular head and neck reconstruction by quantitative analysis of dynamic-enhanced computed tomography. Methods Fifty-one consecutive patients who underwent free jejunum transfer following total pharyngolaryngectomy between January 2017 and December 2020 were retrospectively reviewed. Ninety-four pairs of the diameters of the transverse cervical artery, superior thyroid artery, and lingual artery, measured via computed tomography angiography, were analyzed. Operative outcomes were compared between the following groups based on the recipient artery: transverse cervical artery (n = 27), superior thyroid artery (n = 17), and other artery (n = 7) groups. Results In the analysis of the computed tomography angiography, nine transverse cervical arteries (9.6%) could not be identified. However, the percentage was significantly lower than the percentage of superior thyroid arteries (20.2%) and lingual arteries (18.1%) (p < 0.01). Among the identified vessels, the transverse cervical arteries (2.09 ± 0.41 mm) and the lingual arteries (1.97 ± 0.40 mm) were significantly larger than the superior thyroid arteries (1.70 ± 0.36 mm) in diameter at the commonly used level (p < 0.01). Multivariate analysis revealed that prior radiation therapy was not an independent factor significantly affecting transverse cervical artery diameter (p = 0.17). Intraoperative anastomotic revision was required in only two cases of the superior thyroid artery. Conclusion The transverse cervical artery can offer a larger caliber and more reliable candidate than the superior thyroid artery for a recipient artery. More liberal use of the transverse cervical artery may improve the safety of microsurgical head and neck reconstruction. [ABSTRACT FROM AUTHOR]

Background: Perfused placentas provide an excellent and accessible model for microvascular dissection, microsuturing and microanastomosis training — particularly in the early microsurgical learning curve. This way, a significant amount of live animals can be spared. Method: We present the Zurich Microsurgery Lab protocol, detailing steps for obtaining, selecting, cleaning, flushing, cannulating, and preserving human placentas — as well as microsurgical training examples — in a tried-and-true, safe, cost-effective, and high-yield fashion. Conclusion: Our technique enables highly realistic microsurgical training (microdissection, microvascular repair, microanastomosis) based on readily available materials. Proper handling, preparation, and preservation of the perfused placenta models is key. [ABSTRACT FROM AUTHOR]

Background The complexity of plastic microsurgery yields many risks. Robot assistance has been sought to maximize outcome and minimize complications. Reportedly, it offers increased dexterity and flexibility with attenuated human flaws, such as tremors and fatigue. This systematic review will further investigate that claim.

Background Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on postoperative patient outcomes and surgical costs. Methods A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and postoperative outcomes were collected. Data were analyzed using Student's t -tests, Chi-square analysis, and multivariate logistic regression. Results Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (odds ratio [OR] 1.02, 95% confidence Interval [CI] 1.00–1.03, p <0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01–6.34, p <0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02–0.60, p <0.05). Intraoperative anastomotic failure increased the odds of postoperative hematoma (OR 8.85, CI 1.35–59.1, p <0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, p <0.05), longer hospital stays (2.2 days longer, p <0.05), and higher total operating room cost ($28,529.50 vs. $37,272.80, p <0.05). Conclusion Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of postoperative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success. [ABSTRACT FROM AUTHOR]

Abstract Objective Analyze efficacy of self‐directed resident microvascular training versus a mentor‐led course. Study Design Randomized, single‐blinded cohort study. Setting Academic tertiary care center. Methods Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self‐directed microvascular course with instructional videos and self‐directed lab sessions. Group B completed a traditional mentor‐led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post‐course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective‐structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA). Results The pre‐course assessment identified that the groups were well matched with only “Economy of Motion” on the GRS favoring the mentor led group (p = .02). This difference remained significant on the post assessment (p = .02) Both groups significantly improved in OSATS and GRS scoring (p .99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p = .005) with no significant difference between post training times to complete (p = .63). Conclusion Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self‐directed microsurgical training model is an effective alternative to a traditional mentor driven models. Level of Evidence Level 2.

A narrow working space, small diameters, and the tendency to collapse with clamps make cerebral microvascular anastomosis challenging. A retraction suture (RS) is a novel technique to keep the recipient vessel lumen open during the bypass. To provide a step-by-step overview of RS for end-to-side (ES) microvascular anastomosis on rat femoral vessels and successful use for superficial temporal artery to middle cerebral artery (STA-MCA) bypass in Moyamoya disease patients. A prospective experimental study with approval from the Institutional Animal Ethics Committee. Femoral vessels ES anastomoses were performed on Sprague Daley rats. The rat model used 3 types of RS (adventitial, luminal, and flap RSs). An ES-interrupted anastomosis was done. The rats were observed for an average period of 16.18 ± 5.65 days; the patency was assessed by reexploration. The immediate patency on the STA-MCA bypasses was confirmed with intraoperative indocyanine green angiography and micro-Doppler; delayed patency with magnetic resonance imaging and digital subtraction angiography after 3–6 months. In the rat model, 45 anastomoses were performed, 15 each using the 3 subtypes. The immediate patency was 100%. Delayed patency was 42/43 (97.67%), and 2 rats died during observation. In the clinical series, 59 STA-MCA bypasses were done in 44 patients (average age, 18.14 ± 11.09 years) using RS. The follow-up imaging was available for 41/59 patients. Both immediate patency and delayed patency (41/41 at 6 months) were 100%. The RS allows continuous visualization of the vessel lumen, reduces the handling of intimal edges, and avoids incorporating the back wall in sutures, thus improving anastomosis patency. [ABSTRACT FROM AUTHOR]

This study aimed to elucidate the vasodilatory effects and cytotoxicity of various vasodilators used as antispasmodic agents during microsurgical anastomosis. Rat smooth muscle cells (RSMCs) and human coronary artery endothelial cells (HCAECs) were used to investigate the physiological concentrations and cytotoxicity of various vasodilators (lidocaine, papaverine, nitroglycerin, phentolamine, and orciprenaline). Using a wire myograph system, we determined the vasodilatory effects of each drug in rat abdominal aortic sections at the concentration resulting in maximal vasodilation as well as at the surrounding concentrations 10 min after administration. Maximal vasodilation effect 10 min after administration was achieved at the following concentrations: lidocaine, 35 mM; papaverine, 0.18 mM; nitroglycerin, 0.022 mM; phentolamine, 0.11 mM; olprinone, 0.004 mM. The IC50 for lidocaine, papaverine, and nitroglycerin was measured in rat abdominal aortic sections, as well as in RSMCs after 30 min and in HCAECs after 10 min. Phentolamine and olprinone showed no cytotoxicity towards RSMCs or HCAECs. The concentrations of the various drugs required to achieve vasodilation were lower than the reported clinical concentrations. Lidocaine, papaverine, and nitroglycerin showed cytotoxicity, even at lower concentrations than those reported clinically. Phentolamine and olprinone show antispasmodic effects without cytotoxicity, making them useful candidates for local administration as antispasmodics. [ABSTRACT FROM AUTHOR]

Introduction: Severe aqueous tear deficiency is caused by primary or secondary main lacrimal gland insufficiency. The transplantation of a human lacrimal gland could become a potential treatment option to provide physiological tears with optimal properties. To this end, we performed an ex vivo study to develop a surgical strategy that would ensure a vascular supply for a lacrimal gland transplant using microvascular techniques. Material and methods: Five cadaver heads were used to perform a lateral orbitotomy in order to identify the vascular pedicle and the lacrimal gland itself. The principal feasibility and the time of the required surgical steps for an intraorbital microvascular re-anastomosis of the human lacrimal gland were documented. Patency and potential leakage of the anastomosis were tested with hematoxylin intraoperatively. Postoperatively, routine histological, as well as scanning electron microscopy (SEM) of the gland and vascular anastomosis, were performed. Results: The vascular pedicle of all five glands could be isolated over a minimum stretch of at least 1 cm, severed, and successfully reanastmosed microsurgically. Time for arterial anatomization (n = 4) was 23 ± 7 min and 22 ± 3 min for the vein (p = 0.62). The total time for the entire microvascular anastomosis was 46 ± 9 min. All anastomosis were patent upon testing. SEM revealed well-aligned edges of the anastomosis with tight sutures in place. Conclusion: Our study demonstrates as proof of principle the feasibility of intraorbital microvascular re-anastomosis of a human lacrimal gland within the presumed window of ischemia of this tissue. This should encourage orbital surgeons to attempt lacrimal gland transplantation in humans in vivo. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recently, numerous basic and clinical data have shown the superiority of platelet-rich fibrin in the regeneration and repair of soft and hard tissues, while there are few relevant reports in the field of microvascular anastomosis. OBJECTIVE: To evaluate the efficacy of platelet-rich fibrin applied to the femoral artery after microvascular anastomosis surgery in a rabbit model. METHODS: Thirty-six adult New Zealand white rabbits of either sex were randomly divided into experimental group and control group (n=18 per group) after establishing femoral artery transection-reanastomosis models. In the experimental group, autologous ear venous blood were extracted and centrifuged to prepare platelet-rich fibrin gel, and the prepared gel was immediately applied to the anastomotic site of the femoral artery. The control group was given the same volume of normal saline. Incision infection, healing, and adhesion were evaluated at 3, 7, 14 days after surgery. Vascular structure of the femoral artery at the anastomotic site was observed using hematoxylin-eosin staining. Immunohistochemistry detection was performed to analyze the expression levels of vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor β1. RESULTS AND CONCLUSION: The overall number of incision infections in the experimental group was lower than that in the control group animals (P < 0.05), and the number of incision infections showed no significant changes in each group (P > 0.05). The overall incision healing level in the experimental group was better than that in the control group (P < 0.05), and the incision healing showed no significant changes in the experimental group (P > 0.05) but changed significantly in the control group at different time points (P < 0.05). The degree of femoral artery adhesion in the operation area was generally lighter in the experimental group than the control group (P < 0.05). The degree of adhesion had insignificant changes in the experimental group at different time points (P > 0.05) but gradually increased in the control group after operation (P < 0.05). The results of hematoxylin-eosin staining showed better repair of vascular endothelial cells and inner elastic lamina in the experimental group than the control group. Compared with the control group, the reconstruction of the intima was more complete in the experimental group, with less necrosis, proliferation, and migration of vascular smooth muscle cells in the media and traumatic hyperplasia of the extima. The overall healing condition of the vascular wall was better in the experimental group than the control group. Immunohistochemical results revealed that the expression levels of vascular endothelial growth factor, platelet-derived growth factor, and transforming growth factor β1 in the experimental group were higher than those in the control group (P < 0.05). To conclude, platelet-rich fibrin can promote the growth of vascular endothelial cells, contribute to the in situ reconstruction of various layers of vascular tissue, reduce postoperative complications, such as infection and adhesion, in the surgical area, and shorten the repair and healing time after vascular injury. This novel treatment method is expected to improve the therapeutic effect of arterial anastomosis in microsurgery. [ABSTRACT FROM AUTHOR]

Objective: Superior thyroid artery (SThA) is a common recipient artery in free tissue transfer even after total pharyngolaryngoesophagectomy (TPLE) with hemithyroidectomy. The aim of this study was to evaluate whether the use of SThA as a recipient vessel affect thyroid function in patients undergoing TPLE with hemithyroidectomy. Methods: From 2011 to 2020, 91 patients who underwent free jejunum transfer after TPLE with hemithyroidectomy were divided into two groups. In Group1 (n = 47), the contralateral SThA was used for the anastomosis. In Group2 (n = 44), other vessels were used. Retrospective chart review was performed comparing postoperative thyroid function between two groups. Results: In group1, 17 patients presented hypothyroidism, 21 presented latent hypothyroidism and 9 presented no thyroid dysfunction comparing 15, 19, and 10 respectively in group 2. There were no significant differences between the two groups. Conclusion: Even after hemithyroidectomy, with inferior thyroid arteries are preserved, the SThA can be used as a recipient vessel. Level of Evidence: 3 Laryngoscope, 133:557–561, 2023 [ABSTRACT FROM AUTHOR]

Microvascular anastomosis is one of the most challenging neurosurgical techniques. Mastering this technique allows to perform intracranial bypass with arteries of small caliber usually placed in deep narrow surgical fields. The aim of this paper is to describe step by step end-to-side microanastomosis training method by using polyvinyl alcohol (PVA) hydrogel tubing as it is easily reproducible. The tubing comes in sizes from 0.3 mm to 5 mm and has a texture and consistency similar to real vessels. This is based on the Teishinkai Hospital anastomosis technique. Continuous practice in microvascular anastomosis is of great importance in training vascular neurosurgeon. The PVA hydrogel tubing described in this article are useful and cost-effective material in the training of microvascular anastomosis. This practical guide model is easy to set up for repeated practice, and will contribute to facilitate 'off-the-job' training by young neurosurgeons and the development and maintenance of microsurgical skills in both resident neurosurgeons and experts who wish to master the various levels of anastomosis technique. There is no shortcut to master this technique, only hard work and perseverance. [ABSTRACT FROM AUTHOR]

To introduce a new knotting technique for vascular anastomosis, which was different from the conventional knotting methods, is the aim of this study. A microsurgeon learned this technique and practiced on gauze, and then he used this new technique to perform vascular anastomosis. The times that he spent with this new technique and conventional method were recorded and compared. After this new technique was applied, the speed of vascular anastomosis was reduced compared with conventional method, and the difference showed statistical significance. This new knotting technique can avoid the adherence of the suture to the soft tissue during knotting and can be knotted rapidly and continuously. In particular, the surgeon can perform this technique without the help of an assistant. [ABSTRACT FROM AUTHOR]

Background: Vascular anastomosis, which is usually performed during complex surgical procedures such as transplantation and reconstruction, is a time-consuming and skilled practice. The aim of this study is to compare the vascular anastomosis technique made with minimal suture and chitosan with the traditional technique. Methods: Twenty adult female Wistar Albino rats were randomly divided into two groups, the control group (n = 10) in which the traditional hand-sewn technique was applied and the chitosan group (n = 10) with the minimal suture technique. The duration of anastomosis, patency rates on the first and 28th days, and histopathology of the vessels on the 28th day were evaluated. Results: The mean duration of anastomosis was calculated as 19.18 ± 1.79 min in the control group and 11.30 ± 0.97 min in the chitosan group. The difference between the two groups was statistically significant (p < 0.001). There was no significant difference between the patency rates of the control and chitosan groups, both within group (between the 1st and 28th days) and between the groups by day. In histopathological examination, especially in the control group, transmural damage, foreign body reactions due to the suture material, and granulomas were observed around the suture, while perivascular foreign body reactions were observed less frequently in the chitosan group compared to the control group. Conclusion: We have shown that this new method of microvascular anastomosis is effective, easy to learn, and requires less time than conventional sutures. However, other studies should be conducted to prove the feasibility of this new technique and to prove its long-term success and results in the vessels. [ABSTRACT FROM AUTHOR]

Objective: Analyze efficacy of self‐directed resident microvascular training versus a mentor‐led course. Study Design: Randomized, single‐blinded cohort study. Setting: Academic tertiary care center. Methods: Sixteen resident and fellow participants were randomized into two groups stratified by training year. Group A completed a self‐directed microvascular course with instructional videos and self‐directed lab sessions. Group B completed a traditional mentor‐led microvascular course. Both groups spent equal time in the lab. Video recorded pre and post‐course microsurgical skill assessments were performed to assess the efficacy of the training. Two microsurgeons, blinded to participant identity, evaluated the recordings and inspected each microvascular anastomosis (MVA). Videos were scored using an objective‐structured assessment of technical skills (OSATS), a global rating scale (GRS), and quality of anastomosis scoring (QoA). Results: The pre‐course assessment identified that the groups were well matched with only "Economy of Motion" on the GRS favoring the mentor led group (p =.02). This difference remained significant on the post assessment (p =.02) Both groups significantly improved in OSATS and GRS scoring (p <.05). There was no significant difference in OSATS improvement between the two groups (p =.36) or improvement in MVA quality between groups (p >.99). Time to completion of MVA significantly improved overall by a mean of 8 min and 9 s (p =.005) with no significant difference between post training times to complete (p =.63). Conclusion: Different microsurgical training models have previously been validated as effective methods for improved MVA performance. Our findings indicate that a self‐directed microsurgical training model is an effective alternative to a traditional mentor driven models. Level of Evidence: Level 2. We designed a randomized, single‐blinded cohort study to analyze the efficacy of self‐directed resident microvascular training compared to a mentor‐led course. Our results suggest that a self‐directed microsurgical training model is an effective alternative to more traditional models. [ABSTRACT FROM AUTHOR]

Objective To compare the histopathology of patent and nonpatent microvascular anastomosis using rat femoral artery end-to-end anastomosis model. Materials and Methods In 15 Sprague–Dawley rats, end-to-end anastomosis was performed on the right femoral artery. The classical method was used in four cases and one-way up method in 11 cases. The animals were sacrificed after 2 weeks and the anastomosis was subjected to histopathology. The pathological changes in patent and nonpatent cases were compared. Results The immediate patency rate and delayed patency (after 2 weeks) rate was 86.7% and 66.7%, respectively. The mean follow-up was 3 months. At sacrifice, 5/15 anastomosis were not patent. Marked subintimal thickening was noted in ⅘ (80%) of the nonpatent group, which was absent in the patent group. Severe loss or fibrosis of tunica media and marked adventitial inflammation were noted in all nonpatent cases (5/5, 100%). As much as ⅘ of the nonpatent cases had poor or indeterminate apposition; in contrast, good apposition was seen in 6/10 (60%) of the patent group. The mean clamp time and mean suturing time were significantly longer in the nonpatent group (69.2 minutes and 53.8 minutes, respectively) as compared with the patent group (48.8 minutes and 31.8 minutes, respectively). A single case that was initially nonpatent was found to have recanalized at 6 months. Conclusion Minimal intimal injury and reaction, minimal thinning of tunica media, mild-to-moderate adventitial changes, good apposition, and equidistant sutures were associated with a successful microvascular anastomosis. Short duration of vessel clamping time and suturing comes with experience and dedicated practice in a skills laboratory.

The objective was to explore possibilities with reconstruction of opposable digital stump of the hand transplanted with microvascular anastomoses in frostbite patients. Material and methods Medical histories and long-term results of treatment of two frostbite patients with finger stumps of both hands were reviewed. The triphalangeal finger and the thumb were reconstructed by transplanting the opposable finger stump together with the metacarpophalangeal joint using microvascular and microneural anastomoses. The stumps were mobilized and transplanted to the distal ulnar artery with the venous drainage performed using the dorsal saphenous vein of the hand. Long-term results were examined at 10 years and 2.5 years of surgery. Clinical, radiological, biomechanical and biophysical investigations were produced. Results The bilateral gripping function was restored in recipient stumps without functional damage to the donor stumps. Discriminatory sensitivity of reconstructed fingers was 6mm and 8 mm, the range of active motion in the transplanted joint was 55 and 66 degrees. Discussion Opposable digital stump transplantation with microvascular anastomoses has significant advantages over the classical surgery. The technique allows for one-stage restoration of a finger to have sufficient length, function, adequate blood supply and innervation due to a short digital stump being transplanted with the metacarpophalangeal joint. The advantage over a toe transplant consists of the use of digital structures of the hand that are identical in functionality and the anatomy reducing the need for secondary interventions. Conclusion The method of management can be successfully applied for frostbite patients with hand stumps according to indications.

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury. [ABSTRACT FROM AUTHOR]

Background: Previous computed tomography studies have reported that the superior mesenteric artery is often located ventrally to the superior mesenteric vein; however, the precise location of the peripheral jejunal arteriovenous system is unknown. This study investigated the arteriovenous positioning of the free jejunal flaps during reconstructive surgery., Methods: This retrospective cohort study included 78 patients who underwent free jejunal flap reconstruction between June 2021 and May 2023. The positions of the jejunal artery and vein were classified into 6 patterns (A-F) based on the photographs taken during the flap harvest. Statistical analysis was performed to examine the location of the artery (ventral vs. dorsal) and its orientation along the oral-anal axis in relation to the vein., Results: The jejunal arteries were most commonly located on the oral and ventral sides of the vein (type A, 48.6%) when the mesentery of the jejunal flap is positioned toward the front, with the left and right sides corresponding to the oral and anorectal sides, respectively. Notably, 62.1% of the arteries were located on the oral side and 71.6% on the ventral side. The recipient arteries used for vascular anastomosis were predominantly the superior thyroid artery (44.6%) and transverse cervical artery (50.0%), while the internal jugular vein (85.1%) was the most commonly used vein., Conclusion: The position of the jejunal arteriovenous system is important for optimizing anastomotic techniques and ensuring safe surgical outcomes. Understanding vascular anatomy patterns can help prevent vessel misplacement and allow for more reliable and accurate anastomosis procedures., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background  Repetitive training is essential for microsurgical performance. This study aimed to compare the improvement in basic microsurgical skills using two learning methods: stationary microsurgical course with tutor supervision and self-learning based on digital instructional materials. We hypothesized that video-based training provides noninferior improvement in basic microsurgical skills. Methods  In this prospective study, 80 participants with no prior microsurgical experience were randomly divided into two groups: the control group, trained under the supervision of a microsurgical tutor, and the intervention group, where knowledge was based on commonly available online instructional videos without tutor supervision. Three blinded expert microsurgeons evaluated the improvement in basic microsurgical skills in both groups. The evaluation included an end-to-end anastomosis test using the Ten-Point Microsurgical Anastomosis Rating Scale (MARS10) and a six-stitch test on a latex glove. Statistically significant differences between groups were identified using standard noninferiority analysis, chi-square, and t -tests. Results  Seventy-seven participants completed the course. Baseline test scores did not differ significantly between groups. After the 4-day microsurgical course, both groups showed statistically significant improvement in microsurgical skills measured using the MARS10. The performed tests showed that data for self-learning using digital resources provides noninferior data for course with surpervision on the initial stage of microsurgical training (7.84; standard deviation [SD], 1.92; 95% confidence interval [CI], 7.25–8.44) to (7.72; SD, 2.09; 95% CI, 7.07–8.36). Conclusion  Video-based microsurgical training on its initial step provides noninferior improvement in microsurgical skills to training with a dedicated instructor. [ABSTRACT FROM AUTHOR]

BackgroundThree-dimensional (3D) exoscope systems have been developed and are reported to be adequate alternatives to the conventional microscope. This study aimed to evaluate the feasibility and effectivity of microvascular anastomosis using a 4 K 3D exoscope in an in vivo animal study.MethodsThe abdominal aortas of mice were selected as the target vessels for comparing the outcomes of microvascular anastomosis for both the conventional microscope and 3D exoscope. We recorded the vessel separation, temporary occlusion, and total procedure durations. Local conditions at the sutures were also recorded. Typical histopathological images were presented, and the patency of anastomotic vessels within 5 and 30 min were evaluated. All procedures included both superficial and deep anastomosis.ResultsSixty mice were included in the analysis; the weight and vascular diameter were 38.5 ± 5.8 g and 0.77 ± 0.06 mm, respectively, and around 8 stiches were required. Regarding feasibility, vessel separation duration, temporary occlusion duration, total procedure duration, blood leak, and number of vascular folds between stiches, the results were comparable between the two types of microscopes. The feasibility of anastomosis was also confirmed by pathology. Regarding effectiveness, anastomotic vascular patency at 5 and 30 min were similar for both microscopes. Even in the more difficult scenario of deep anastomosis, the results were comparable.ConclusionsIn a challenging experimental setting, comparable outcomes of microvascular anastomosis were observed for the conventional microscope and 3D exoscope in these animal experiments. Therefore, in vivo microvascular anastomosis is feasible and effective using a 3D exoscope.

Background: Microvascular reconstruction remains challenging In previously operated and irradiated patients, especially when double flaps seem to be the only solution due to osteoradionecrosis. An alternative reconstructive option could be microvascular anastomosis to the temporal vessels to avoid the obligatory cervical incision. Methods and Materials: All consecutive cases between January 2013 and 2020 that underwent either mandibular resection and reconstruction with a free fibula flap (FFF) and another soft tissue flap (group I) or pure intraoral resection and reconstruction with an FFF or radial forearm flap (RFF) with temporal microvascular anastomosis (group II) were included. Patients' general information, indication and extent of surgery, time of ischemia, time of total surgery, and duration of hospital stay as well as incidence of complications were retrospectively recorded and analyzed. Results: Seventeen (group I) and 11 (group II) cases were included. In group I, FFF was combined with RFF (n = 9), anterolateral thigh flap (ALT, n = 7), or latissimus dorsi flap (n = 1). Group II consisted of six FFFs and five RFFs. Operation time and hospitalization duration were significantly shorter in group II (p < 0.001 and p = 0.025), whereas ischemic time of FFF was significantly shorter in group I (p = 0.002). All patients in group I required a tracheostomy, while only four cases in group II did (p = 0.004). The complication rate regarding hematoma removal, revision of anastomosis, flap loss, delirium, sepsis, pleural effusion, pneumonia, and pulmonary artery embolism showed no significant differences between the two groups. Conclusions: The superficial temporal vessels served as versatile recipient vessels for Intraoral mandibular and soft tissue reconstruction and led to reduced operation time, hospitalization duration, and indication for a primary tracheostomy. Thus, this approach may help to avoid cervical incision for reconstruction in irradiated patients. [ABSTRACT FROM AUTHOR]

Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group (p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes (p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss (p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

BackgroundMicrovascular reconstruction remains challenging in previously operated and irradiated patients, especially when double flaps seem to be the only solution due to osteoradionecrosis. An alternative reconstructive option could be microvascular anastomosis to the temporal vessels to avoid the obligatory cervical incision.Methods and MaterialsAll consecutive cases between January 2013 and 2020 that underwent either mandibular resection and reconstruction with a free fibula flap (FFF) and another soft tissue flap (group I) or pure intraoral resection and reconstruction with an FFF or radial forearm flap (RFF) with temporal microvascular anastomosis (group II) were included. Patients’ general information, indication and extent of surgery, time of ischemia, time of total surgery, and duration of hospital stay as well as incidence of complications were retrospectively recorded and analyzed.ResultsSeventeen (group I) and 11 (group II) cases were included. In group I, FFF was combined with RFF (n = 9), anterolateral thigh flap (ALT, n = 7), or latissimus dorsi flap (n = 1). Group II consisted of six FFFs and five RFFs. Operation time and hospitalization duration were significantly shorter in group II (p

Objective  To compare the histopathology of patent and nonpatent microvascular anastomosis using rat femoral artery end-to-end anastomosis model. Materials and Methods  In 15 Sprague–Dawley rats, end-to-end anastomosis was performed on the right femoral artery. The classical method was used in four cases and one-way up method in 11 cases. The animals were sacrificed after 2 weeks and the anastomosis was subjected to histopathology. The pathological changes in patent and nonpatent cases were compared. Results  The immediate patency rate and delayed patency (after 2 weeks) rate was 86.7% and 66.7%, respectively. The mean follow-up was 3 months. At sacrifice, 5/15 anastomosis were not patent. Marked subintimal thickening was noted in ⅘ (80%) of the nonpatent group, which was absent in the patent group. Severe loss or fibrosis of tunica media and marked adventitial inflammation were noted in all nonpatent cases (5/5, 100%). As much as ⅘ of the nonpatent cases had poor or indeterminate apposition; in contrast, good apposition was seen in 6/10 (60%) of the patent group. The mean clamp time and mean suturing time were significantly longer in the nonpatent group (69.2 minutes and 53.8 minutes, respectively) as compared with the patent group (48.8 minutes and 31.8 minutes, respectively). A single case that was initially nonpatent was found to have recanalized at 6 months. Conclusion  Minimal intimal injury and reaction, minimal thinning of tunica media, mild-to-moderate adventitial changes, good apposition, and equidistant sutures were associated with a successful microvascular anastomosis. Short duration of vessel clamping time and suturing comes with experience and dedicated practice in a skills laboratory. [ABSTRACT FROM AUTHOR]

Background Ameloblastoma is a benign yet locally aggressive odontogenic tumor of the jaw with high recurrence rates. Despite many studies, the search is still on for the treatment approach which can render the acceptable recurrence rates with good functional and esthetic results. Methods In this prospective study, we operated on 37 patients of mandibular ameloblastoma between 2009 and 2018. Two patients were treated with curettage and chemical sterilization of the cavity. Resection of a tumor with a 2-cm margin was performed in the rest of 35 patients. The mandibular defect was primarily reconstructed with the microvascular free fibular flap in 29 patients. Results The follow-up ranged from 6 months to 7.7 years with a mean of 5.1 years. A tumor recurred within a year in all two patients (100%) treated with curettage. Out of 35 radical excisions, only one patient (2.85%) developed recurrence 3 years after the disease-free interval. Good mouth opening, intelligible speech, satisfactory lower jaw shape, and facial profiles were achieved in all 29 patients who were treated with primary free fibular flap. Conclusion We prefer wide excision with 2-cm margins on each side of a tumor with the primary reconstruction of the mandible in all cases of mandibular ameloblastoma. The free fibular microvascular flap is our treatment of choice as all defects of the mandible can be reconstructed with the free fibular flap. Wide excision is the key to prevent a recurrence.

Background The Exoscope is a novel high-definition digital camera system. There is limited evidence signifying the use of exoscopic devices in microsurgery. This trial objectively assesses the effects of the use of the Exoscope as an alternative to the standard operating microscope (OM) on the performance of experts in a simulated microvascular anastomosis. Methods Modus V Exoscope and OM were used by expert microsurgeons to perform standardized tasks. Hand-motion analyzer measured the total pathlength (TP), total movements (TM), total time (TT), and quality of end-product anastomosis. A clinical margin of TT was performed to prove non-inferiority. An expert performed consecutive microvascular anastomoses to provide the exoscopic learning curve until reached plateau in TT. Results Ten micro sutures and 10 anastomoses were performed. Analysis demonstrated statistically significant differences in performing micro sutures for TP, TM, and TT. There was statistical significance in TM and TT, however, marginal non-significant difference in TP regarding microvascular anastomoses performance. The intimal suture line analysis demonstrated no statistically significant differences. Non-inferiority results based on clinical inferiority margin (Δ) of TT=10 minutes demonstrated an absolute difference of 0.07 minutes between OM and Exoscope cohorts. A 51%, 58%, and 46% improvement or reduction was achieved in TT, TM, TP, respectively, during the exoscopic microvascular anastomosis learning curve. Conclusions This study demonstrated that experts’ Exoscope anastomoses appear non-inferior to the OM anastomoses. Exoscopic microvascular anastomosis was more time consuming but end-product (patency) in not clinically inferior. Experts’ “warm-up” learning curve is steep but swift and may prove to reach clinical equality.

Superficial temporal artery (STA) pseudoaneurysm is a very rare occurrence that usually presents as a pulsatile mass along the STA distribution following trauma or an iatrogenic cause. We report a case of STA pseudoaneurysm that developed in a 32 year old male following blunt trauma. Unfortunately, the pseudoaneurysm was missed and led to multiple hospital presentations that culminated in an acute bleeding episode. Surgical resection of the pseudoaneurysm was performed and the STA was reconstructed with an STA-STA anastomosis. To our knowledge, this is the second reported case of an STA pseudoaneurysm treated with an STA-STA anastomosis. This case report aims to bring awareness. Although extremely rare, the importance of treating the presence of a pulsatile mass along the STA distribution following a history of trauma or recent cranial surgery with a high level of suspicion is imperative.

Objective: Microvascular anastomosis is challenging, and training surgeons to develop and maintain skills is imperative. Current training models either miss the simulation of the surgical workflow, lack 3D key-hole space, need ethical approval, require special preparation, or lack realism. To circumvent these issues, this study describes the use of a mixed reality 3D printed model with integrated blood flow for training cerebral anastomosis and assesses its validity., Methods: Different-sized 3D-printed artificial micro artery models in a 3D brain space with a keyhole opening were used. The model was connected to a 4D simulator to induce pulsatile blood flow. Neurosurgical microscopes and exoscopes were used for visualization. Nine participants (n = 6 board-certified cerebrovascular neurosurgeons; n = 3 in-training) participated in the study and practiced anastomosis techniques with the simulator. Two senior, experienced vascular neurosurgeons mentored live teaching activity on the simulator. Participants completed a survey to score the face and content validity of the simulation on a 5-point Likert scale. Simulation time and anastomosis score differences between in-training and board-certified participants were compared for construct validity., Results: Participants scored the simulation difficulty similar to actual surgery, proving face validity. All participants agreed that practice on the provided simulator models would improve bypass techniques ( μ  = 4.67/5 ± 0.47) and instrument handling ( μ  = 4.56/5 ± 0.68). Board-certified participants had better anastomosis scores than in-training participants (non-significant difference)., Conclusions: The 4D simulator and the high-fidelity artificial 3D printed model effectively simulated actual bypass surgery in a key-hole fashion with blood flow abilities. Limited resources and preparation time are needed for the training setup. The model provides benefits in learning and maintaining anastomosis skills and allows for easy adaptation to different microanatomical scenarios., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Fredrick J. Joseph and David Bervini report a relationship with SurgeonsLab AG that includes: board membership and equity or stocks., (© 2024 The Authors.)

Introduction: During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure.Patients and methods: In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications.Results: In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion: Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery.