All right. Good evening. So welcome everyone to the ASSH CME webinar for the month of March. We have great faculty for you presenting some outstanding talks on modern marvels of soft tissue reconstruction. And I just want to remind everybody, if you are registered to claim your CME by Tuesday, March 26, and the login is on your ASSH login dashboard, member dashboard, and that's the method to claim your CME. And I just want to briefly take a moment just to introduce you to our esteemed faculty with us tonight, beginning with Dr. Heather Baltzer, who's at the University of Toronto, our plastic surgery trained colleague. We have Dr. Hooper, who's also plastic surgery trained, who's at the University of Michigan. And my last plastic surgeon faculty, Dr. Inez Lin, who's at the University of Pennsylvania. And then we also have two esteemed orthopedic and colleagues, Dr. Angela Wang at the University of Utah, and Dr. Emily Shin, who is an attending at Madigan Army Medical Center in the orthopedics department there as well. So we, I won't hold up any more time. We'll go ahead and start our webinar. And I'll stop share. First we have for you is Dr. Inez Lin, who is faculty at the University of Pennsylvania. Dr. Lin. Okay, so my charge is to discuss coverage of dermal and epidermal defects with skin grafts. I have no disclosures. I also wanted to have a few other disclaimers. I've used many commercial products for achieving wound closure. I do not have any financial relationships with these companies, and I'm not endorsing one commercial product over another in this talk. My learning objectives today are to understand the evolution of skin grafting, to describe standard and new techniques of skin grafting, including some debated topics of thickness, bolstering donor site management, and how they may improve outcomes and patient experience, and to discuss the use of dermal regenerate templates in order to broaden the indications of skin grafting in certain wounds. As a foundation, upper extremity wounds can result from many issues, burns and other trauma, infection, ischemia, tumor, radiation, and pressure necrosis. Factors to consider when for reconstruction is wound size, depth, anatomic location, exposed structures, tissue quality, including necrosis and infection, and radiation. I acknowledge that some wounds are best served by flap reconstruction. For example, here is a dorsal form with exposed extensor tendon injury, and this was covered with a free anterolateral thigh flap with tendon graft reconstruction with excellent stable soft tissue coverage and good restoration of finger extension. But there are some wounds or some patients that you may not want to consider a free flap for. In Philadelphia, we have a series of terrible upper extremity wounds in patients who inject drugs because of the addition of xylosine or tranq to the fentanyl drug supply, and these wounds are often necrotic, large, and deep. And we have tried to do some free flaps for coverage given the bone exposure, and we've had some failures. And so, can we use advancements in skin grafting techniques to reconstruct wounds like these for patients who are good candidates? And so, with this frame, I would like to review skin grafts for what is the same and what is different, and I've broken it down into these five areas. But first, what is the same? I think just as a foundation, we should recognize that skin includes epidermis and dermis, and it then covers over subcutaneous fat. And the history of skin grafting began in the 1870s with description initially of epidermal skin grafts, which were probably more split thickness skin grafts in reality, followed by full thickness skin grafts, and then a more formal description of split thickness skin grafts. The equipment used to harvest skin grafts has also evolved over time, and this began initially with pinch scissors created by Reverdon, and then we evolved to knives, and then knives with guards such as these Humvee and Watson knives. And then in 1937, the Padgett-Hood dermatome was created, and that evolved into the electric dermatomes that we all use today. And when we think about full thickness, which, as the name says, is epidermis and dermis, versus split thickness, which is epidermis and the upper layer of dermis, there is some debate on which one is better. General thinking is that full thickness skin grafts have less contracture and perhaps better range of motion because of all the layers of skin that's transferred. And I do think that there sometimes can be better aesthetics with a full thickness skin graft. The advantage of split thickness skin graft is larger donor site capacity, so a larger area of graft that you can take. And I do think there is an argument that they take better because it's a thinner area of graft. Also, as a reminder, there is a five-day neovascularization process for a skin graft as it takes. The first 48 hours is imbibation, followed by inosculation, which is the connections of the vessel ends from the wound bed to the graft. And then at five days, you have revascularization with new vessel in growth and to the skin graft. And the general principles about when a wound can get a skin graft is that the wound should be clean and well vascularized in order to support revascularization of the tissue. This means that there should be minimal exposures of what we consider the white structures, which include bone without periosteum, tendon without peritonin, and neurovascular structures. Other considerations are that skin grafts should be used and oriented in a way to limit risk of joint contracture. And some people argue against using skin grafts in areas of friction or significant weight bearing. And these principles continue to underpin our approach to using skin grafts. But I think that there are still a lot of new innovations that can allow us to maximize success with skin grafting by pushing the envelope in which wounds can get skin grafts, as well as improving our success with using them. I'm going to kind of break down the skin grafting process into a few steps and talk about some of these new innovations. So first prepping the wound. So cleaning the wound of necrotic tissue and infection is critical before coverage. And some of these are fairly tried and true and things that we've been doing for centuries. And these include things like mechanical debridement with wet to dry dressings, rough debridement, such as curatage, sharp excisional debridement with knife and scissors. But there have been some new things out there for surgical debridement, including modalities using ultrasound, hydro surgery, and plasma-mediated coblation. Topical agents have also evolved, taking advantage of autolytic enzymatic debridement using hydrogel or honey-based agents. And then topicals with exogenous enzymes, including collagenase and fapane urea. And then after you prep the wound, we have a huge advance with dermal regenerate templates that allow us to put skin grafts in wounds that we typically wouldn't necessarily consider candidates for skin grafting. And I think we all know about wounds with exposed bone at the base, such as this distal phalanx after Lowe's micrographic surgery for skin cancer resection. So this patient had a dermal regenerate template applied, followed by full thickness skin grafting four weeks later. And another similar patient with full excision of a skin tumor, followed by dermal regenerate template, followed by full thickness skin grafting with good preservation of the digit and thumb motion. The concept of dermal regenerate templates is to allow myofibroblasts to migrate into the wound because of the coverage of the template. And that can simulate collagen production to provide a scaffold for cellular in-growth and angiogenesis. And this is mediated by an upregulation of matrix metalloproteinases and other growth factors. So this is a very busy slide, but this table outlines several commonly used and FDA approved dermal regenerate templates that I think are commonly used in a lot of our practices today. This is in the handout that will be distributed. So I won't slow down the talk with going through all of these in detail, but I have included the product name, composition of the product, and some, I think, relevant technical considerations. So putting these first two things together, we return back to my patient with the xylosine form wound with exposed desiccated ulna. I used a combination of direct excision and hydrocertical debridement for soft tissue debridement, and then conservatively debrided the ulna over multiple surgeries with a burr to get to bleeding bone and soft tissues. So this picture on the upper left shows those serial debridements with the bony burring. And then I used a dermal regenerate template on the bottom left to stimulate granulation tissue over the entire wound, including the exposed ulna. And you can see the final photograph before skin grafting on the right with granulation tissue over everything. So now that I have a clean, well-vascularized wound with minimal exposed white structures in an anatomic region that should not have issues with joint contractures, I think we're ready for skin grafting. And what can I do to optimize my skin graft result? So before I go into some new things, I wanted to kind of take a step back and talk about some principles and discussion points for split thickness skin graft versus full thickness skin grafting. And I'm going to talk a little bit about And in general, I prefer to use split thickness skin graft. When I'm doing it, I use it for wounds that I think want that I have a large area or, you know, there's not a lot of depth to it. And so this is an ideal wound. It's fairly shallow. You know, I want to do a skin graft to get coverage quickly. And I do like to, in general, when I can, do it as a sheet graft without meshing it because I do think that the aesthetics of a sheet graft are better. You can see this is another example. This is on the foot, obviously, but again, a sheet graft used without meshing. I like a split thickness skin graft in the lower extremity because I think that the edema of the lower extremity, it's that I want to get every, optimize the situation for healing. So I tend to use split thickness skin grafts, even for small wounds on the foot. And I like the sheet graft because of the smooth, even contour. But meshing the skin graft does have a few advantages. It allows for a piece of skin graft to cover a larger area. It also provides more cutaneous edges for re-epithelialization and the spaces created from the mesh allow for better drainage of serum and blood to increase the likelihood of graft take. It is important when you aren't meshing your skin graft to remember that it is important to cut vents or pie crust holes into the sheet graft to allow for egress of fluid from under the graft. But there is a new technology available now to actually allow for even more expansion of your split thickness skin graft to cover larger areas. And I've just started using this recently. This is a Re-Cell. It is an FDA approved point of care kit to create an autologous cell suspension spray to augment the mesh split thickness skin graft. So this was initially approved for burn care in 2018 and last year in 2023 was approved for other full thickness wounds. It involves taking a small piece of split thickness skin graft and soaking it in trypsin to break down the epidermal components that are then scraped off of the deeper dermis. And then a cell suspension is created and sprayed over the mesh skin graft. So this is that xylosine forearm wound patient who had a mesh skin graft. And what you can see is I was actually able to her donor site on the thigh is on the right. And you can see that it was able to take a much smaller piece of skin graft and mesh it at a higher ratio. So this is a three to one mesh. I normally do a one and a half to one mesh. And this is the bottom left is a two month post-operative result. And I do think that the quality of the skin graft is better than a lot of times with one and meshing skin. I feel like there's a lot less waffling and her healing was very quick. So to take a step back full thickness skin grafts for wounds on the hand because the wound area is smaller and so I can close the donor site primarily and not have to deal with two to three weeks of donor site care. And because the graft is thicker, I think the contour is good and a good match to the adjacent skin with great supple tissues and great range of motion. It is important to recognize that the data does not say that full thickness skin grafts are superior to split thickness skin grafts for grafting in the hand and that there are many studies that show that split thickness versus full thickness are pretty equivalent in terms of no differences of risk of contractors or web creep between the two techniques. Nevertheless, I do think that skin grafts, particularly when you're putting them on the palm are prone to hyperpigmentation when you compare them to the adjacent skin. And so for patients with darker skin color, this can be quite aesthetically apparent. So you can clearly see that in this patient with full thickness burns to the palm. We did skin grafting and she recovered well with healed wounds and great finger extension and flexion, but the cosmetic appearance of the result is not as ideal. So one option to improve this is using glabral skin grafts. This technique involves split thickness skin grafts from the medial plantar arch with a dermatome over two passes. So the first pass is set. These are both fairly thin split thickness skin graft thicknesses, but the first pass is usually set to eight to 12 one thousandths of an inch and that is put aside and saved in a moist sealing gauze. The second pass is then used and applied to the palmar wound inset and then bolstered with your dressing of choice and then a splint. And then that first pass is then placed back onto the medial plantar arch surface and then covered with a nonstick dressing and a lower leg splint. And this is a published example of using glabral skin grafts to the palm. And I think that you would would agree with me that this has an improved match and skin color and texture compared to my own full thickness skin graft patient that I showed earlier. So for my last two topics, I'm going to talk about bolstering the skin graft and the dress and addressing the donor site. And I think most commonly we do some variation of a tie over bolster over nonstick petroleum gauze like Xeriform and then using something similar to glycerin soaked cotton balls to keep the graft moisturized during those five days of neovascularization. The debate is alternatively you could use a negative pressure wound therapy dressing like a bolster. The advantage of the negative pressure dressing is that it can drain fluid from the wound more effectively. But the advantage of the bolster is that you don't have the burden of being attached to a device for five to seven days as well as dealing with the healthcare cost of the device. There is a recent systematic review and meta-analysis. The meta-analysis involves 653 patients from 12 studies, seven of which were randomized control trials. And they compared both of these dressings. Negative pressure wound therapy did have significantly higher graft take by 7%. It also had something lower rates of reoperation and the two dressings had no difference in infection. So I think you could conclude from this meta-analysis that negative pressure wound therapy dressing is superior. However, if you look at these ranges on my third line there, I would argue that it only has a slight edge that the ranges for both dressings are 86 to 97% versus 84, 94%. So I think that you could argue that both dressings do quite well even if there is a slight edge with negative pressure wound dressing. And so I tend to use a little bit more nuance for dressing my skin graft. I like to use negative pressure wound dressings for my lower extremity skin grafts unless it's a very small graft or I'm doing something on the toe where applying the sponge and the tape may be a challenge. And then in the upper extremity, I would oftentimes use negative pressure wound dressing for a larger skin graft. But I find that a standard bolster with splenomobilization for 7 to 10 days works quite well. In terms of practice management considerations, I do a lot of my skin graft as an outpatient unless someone's already in the hospital. So I do have my office set up an outpatient negative pressure wound device delivery to the patient so that they can bring that and it can be applied in the OR and then manage as an outpatient and not require hospitalization. And then finally, my last topic is dressing the donor site. In my group, and this may be similar in your practices, there is a split amongst surgeons who use a moist donor site dressing such as a Tegaderm and those who use a non-moist dressing such as Xeriform that is allowed to dry over the donor site. And this topic has been debated and studied with multiple systematic reviews over the decades. And the most recent one is from 2018 with a simultaneous meta-analysis that included 35 randomized control trials. They found that moist dressings overall had less pain and that 73% of the articles evaluating moist dressings reported better re-epithelialization rates. The two dressings were equivocal in outcomes regarding infection rate, cosmesis, and cost. So personally, I use Tegaderm over my split thickness donor sites. I think the main criticism of this dressing is the leakage that patients have to deal with for the week or so that the dressing is on. Our practice for those of us who use this dressing, we have a patient education sheet to give patients postoperatively explaining how the dressing works, why we recommend using it, and to expect some drainage. I tell patients they should sit or sleep on some old bath towels to collect drainage. And our nurses often give the patients extra ABD pads and Tegaderms to absorb any drainage and patch up any leaking spots so they can manage it at home. So in summary, we've reviewed some of the established knowledge of skin grafts as well as some newer techniques to improve them, including wound preparation, dermal regenerate templates, concepts of meshing, cell expansion, glabral grafts, and discussed bolstering the graft and how to dress the donor site. And I will open to any questions. Thank you, Dr. Lin. We actually do have a question that was asked through the Q&A, and I apologize for not mentioning it before we began. But attendees, please feel free to type in questions in the Q&A or chat, and we'll address it with the panelists. But we'll start with the first one. Dr. Lin, do you have any experiences with the amount of sensory recovery that you get through the dermal regenerative templates with or without the skin grafting? I have to say, I don't really, I haven't really evaluated that. I think a lot of the skin grafting I do is really over, you know, dorsal surfaces, the palmar surfaces. I don't send patients for SEMS, Weinstein, monofilament testing. Two point, as we know, is standardized more for the fingertips anyways. And, you know, I think a lot of, you know, forearm and upper arm skin grafting, it's sensory is not as critical, but, you know, I don't know if any of the other panelists have any other comments on that. Yeah, I have to say myself, I use this quite a bit as well, and I've never looked into the amount of sensory or protective sensation the patients recover, but I find that they do often definitely have pressure sensation and protective sensation because they can tell when, sort of when you scratch them and palpate the wounds, it's noticeable. But that is an excellent question. Does the other panels have any more experience than that? Well, I would say similar to you, I don't routinely assess them for sensation. In fact, I tell them it's unlikely for a fingertip that they're going to get full sensation. If they're able to get something protective, then great, but it's not an expectation that I have of skin grafts. I just wanted to say, Dr. Lin, that case with the resell and the amount of meshing that you did was phenomenal. That's, that will make me rethink the next exposed dorsal forearm wound that I see, because you went, you really did a great job demonstrating how well that product can work. Thank you. I'm sure they would love to hear that. Yeah, definitely impressed with the amount of exposed ulna that was there and it still got to such excellent closure. Yeah, I mean, I think the teaching for dermal regenerate templates is most times they recommend, the companies, no matter what the product, I feel like they recommend anywhere between two to four weeks to allow for the granulation to form. I will sometimes give it a little bit more time to make sure it's fully established. I find that, you know, even five, six weeks, that wound, because I wanted the skin graft to work perfectly the first time and not have any areas of delayed healing, I just sat on that dermal regenerate template for two to three months. We have a, sorry, Dr. Wang, please. I'll go ahead, answer the incoming questions first. We have a resident from Dartmouth whose question for Dr. Lin was that whether you found fibrin glue improves the extremity skin graft take. That's an excellent question. I have to say, I am just starting to dabble with fibrin glue, so I don't use it a ton. But I know that many of my partners who do a lot of more lower extremity reconstruction use it. It seems like it works very well. And I think, especially if you're meshing your skin graft so you can spray it on top, I think, why not? You know, anything you can do to improve it. I don't think it's going to negatively impact take. Yeah, I agree. I feel like it's a little bit of a pendulum with the fibrin glue and skin grafts. I remember early in residency used a lot and then near the end of my training, it was sort of abandoned. And I am sort of an old school. I suture, you know, all my split thickness and full thickness skin grafts and don't utilize fibrin glue. But certainly if anybody has any experience that does improve take, I'd love to hear it as well. Dr. Hooper. Oh, I don't have a comment on the fibrin glue, but on the topic of dressings for the donor site, I thought that article that you presented, Dr. Lin, was very interesting. Kind of in my training, Tegaderm and Xeroform were the two most commonly used things I've transitioned to use in Mepilex AG because of the silver and the antimicrobial properties that it has, and it's absorptive. So I don't have to deal with the leakage from the Tegaderm as often, and it can stay on for about a week. And I think it's a little less painful to remove compared to the Xeroform which when it gets dry can be really sore for the patient. And that was one of the themes when I was diving into kind of donor site management was that the discussion in that paper and others was that I think there's a lot of new products coming out. And so that I don't think that it's definitive in terms of what's the best way because there may be better things that have yet to be studied. All right, that's questions for now. We can certainly save any more questions for Dr. Lin and the rest of the panelists at the end of the session, but we'll move on to Dr. Hooper and her presentation on more than skin deep beyond the skin. Thank you, Dr. Hooper. Thank you and thank you for inviting me to be a part of this awesome panel. I have no relevant disclosures. In terms of objectives, this is obviously not an exhaustive talk in 15 minutes on regional flap coverage, but my goal here is to highlight some examples for flap reconstruction, both intrinsic as well as regional slash interpolated flaps. I like to think of kind of flap reconstruction as like playing chess. These are a couple of photos of my son and I playing chess. On the left, we're playing at an outdoor park in Detroit. On the right, we're playing in our house. And chess is, as you all know, is very cerebral. You kind of think about your next move and you might even simulate it. And then ultimately you execute. And that's kind of how I approach my soft tissue defects. So we'll just get right into it. The first flap I'm going to briefly discuss some highlights of is the VOLAR V to Y advancement flap. This is a useful flap for fingertip injuries with exposed critical structures like bones seen here in this patient. Defects typically are less than a centimeter. The proximal extent of this flap is the DIP margin crossing the DIP crease increases the risk of flexion contracture. When you incise the flap, you kind of want to cut through the skin dermis and then kind of spread the septa. You don't want to undermine this flap. And you kind of use a skin hook to advance the flap and see where you're being held up before you ultimately inset the flap. With a lot of the advancement flaps that I do, I like to close the donor site to quote unquote, push the flap. And I think a loose inset is really important, particularly in this flap, it's a small flap. And if you put too many sutures, you can cause flap ischemia. So this is the patient at one week and at three weeks. And in terms of dressings, it depends on the patient and the surgeon. This was an elderly patient that was at high risk for trauma to the digit. And so I placed them in a splint, but certainly in a more responsible patient, a soft dressing is very reasonable. The next flap I'll discuss is the cross finger flap. This patient sustained a hedge trimmer injury with a volar defect of the middle finger with some concern for flexor tendon injury. And so in a discussion with this patient, an evaluation of his available donor sites, I proposed to him a cross finger flap. And this is the wound after debridement. And you can see some exposed white structure as mentioned in the previous talk. I like to simulate the flap transfer with this glove. And this is presented in multiple papers as well as the ASSH flap textbook. It's a good teaching tool as well. If you have trainees, you can just put a glove, there's numerous gloves in the OR and you can actually simulate their transfer and help them really understand and convince them that they're elevating the flap based on the right blood vessel. Importantly, you want to make sure that you're maintaining the paratenon over the extensor tendons since you'll be grafting over this site. And here's the flap as it's inset. And I like to put these supportive sutures between the adjacent digits just to support the flap and discourage the patient from significant movement. I splint these patients until their second operation. This is the flap about three weeks post the first operation. And in a darker skin patient, you can see that, and the dorsal skin is pretty dark, but you can use other techniques to monitor the flap such as warmth, turgor, and so forth. Unfortunately for this particular patient, the skin graft didn't take very well. You can see it's kind of necrotic and dehisced with some exposed extensor tendon. At the second operation, you divide the flap as seen here and inset the area that was previously attached. You re-debride the donor site as needed in this particular patient. And I performed a second skin graft. For this, just to piggyback off of the last discussion, I do a tie over bolster in the digit as well. And so this is the patient's outcome after six weeks. As you can see, the hyperpigmentation of the dorsal skin on the roller digit is something that you have to let the patient be aware of. As well as hypopigmentation of a full thickness skin graft, as you can see on the donor site of his digit, but overall reasonable outcome and function. Now I'll transition to talk about thumb reconstruction. This was a patient of mine with a quote unquote rodeo thumb. He was trying to lasso a bull and unfortunately amputated the distal portion of his thumb with exposed proximal phalanx. The kind of workhorse flaps for thumb reconstruction, as we all know, are the Moberg and first dorsal metacarpal artery, as well as a heterodigital. So for this patient, I kind of went through, again, that simulation process with my residents and fellows. So I like to either use a PowerPoint presentation or the iPhone and just kind of simulate where the incisions are gonna be. So for this particular patient, simulating mid-axial incisions. And for this particular patient, simulating what a FDMA flap design would look like. For this particular patient, we ultimately did an extended Moberg, extending the mid-axial incisions with this V to Y extension over the thenar eminence. The third metacarpal is the proximal extent of the flap. And there are fast parts of the operations and slow parts of the operation. And I like to think of this part as kind of the rapid portion of the operation, the radial elevation. You can cross the midline and then you slow down on the ulnar side because there's a higher risk of injuring the neurovascular bundles on that side. Similar to the V to Y advancement flap, I like to close the donor site to kind of push the flap distally and keeping in mind that you may need to flex the MCP for the flap to reach the tip. And again, the use of splint or soft dressing is kind of surgeon and patient dependent. And this is the postoperative outcome after six weeks. This is a patient that I shared with Dr. Haas. A thumb amputation patient where we did a replant that did not survive. And so our backup to preserve length was a first dorsal metacarpal artery flap. Again, in the spirit of templating, here I used a drape to kind of fashion the flap over the patient's index finger. And you can simulate the transposition and make sure that you have appropriate design for the coverage that you intend. And just some sort of key points, again, fast parts of operations, slow parts of operations. So the dissection distally over the proximal phalanx pretty rapid. For this particular patient, we kept a skin paddle over the pedicle. You can certainly skeletonize it if you choose. In addition, you can either tunnel or make a direct incision from your donor site to the recipient. Here for FDMA, you wanna be sure to avoid the web space and avoid creating a web space contracture. For this particular case, we elevated the skin flaps away from our intended flap and tried to preserve as many veins for out flow. Again, you wanna preserve the paratenon and you kind of slow down at the area of the sagittal band, at which point you will transition to a sub-fascial dissection so that you can maintain your blood vessel. And it's perfectly fine to take a little bit of muscle along with the fascia. And here we incised the tunnel and just spread to create a nice path to transpose the flap, closing the donor site first, taking a full thickness skin graft from the volar forearm. And here you can see the flap nicely inset. And for this patient also splinted largely for the skin graft, but also again, to protect the flap. Now we'll transition to regional flaps, the workhorse flap, the reverse radial forearm. This patient had a dorsal wrist defect, prior skin graft with significant extensor tendon adhesions. And so underwent excision of the skin graft and an extensor tenolysis. And so our goal was to provide him with some durable soft tissue coverage to allow the condense to glide a bit better. And so as we all know with the radial artery-based flap, you wanna do an Allen test at the wrist. In this particular case and in all of my cases, I also, during the dissection, when I've isolated the radial artery, I will let down the tourniquet and put an Eklund clamp on the radial artery just to confirm that the hand will be well perfused. You wanna protect the superficial radial nerve, which is deep to the brachial radialis. You wanna preserve the paratenons for grafting. In this particular case, we created a subcutaneous tunnel, but you can also do a direct excision. And when you're passing the flap, you wanna make sure that you can easily get an instrument under your tunnel and obviously you wanna maintain the orientation. And so here's the flap at three weeks right before suture removal. This patient was managed with a wrist orthoplast and we allowed immediate digit range of motion given the tenolysis that was performed. Next will be the posterior interosseous artery flap. This patient sustained a gunshot wound to the thenar eminence. Again, templating your defect to help you design your flap. For this patient, we doppler two perforators and I use a vessel loop, which I often do to kind of measure the length of the pedicle that you'll need with a little bit extra just to accommodate swelling. And so this vessel loop can be taken from the defect to the pivot site and then from the pivot site to the flap proximally allow you to kind of help with the design. It's important for this flap to identify the AIA anastomosis. There are probably two or 3% of patients that don't have it and if they don't, this is not a suitable flap. This is the flap in situ, looks pretty angry. For this particular case, we just elevated the septum with the pedicle, but again, you can take a skin paddle with you. We opened up the transposition site seen here and the lower left is a representative example of a patient with the same flap that had a skin paddle taken. And again, just emphasizing the importance of kind of planning your pedicle, this sort of set almost perfectly and was in set in a very reasonable manner. And I do a split thickness skin graft meshed one-to-one and you wanna close loosely over your pedicle to avoid compression. And I splint these patients again to protect the skin graft as well as to avoid any inadvertent damage to the pedicle. And then later transition to an orthoplast that has a window for flap monitoring. The next flap will just kind of, some high level points on the latissimus flap. So you typically harvest this in the lateral decubitus position. The patient on the left underwent a muscle only latissimus flap position in a lateral decubitus way. And the arm and chest were prepped but kind of covered in this particular patient. Whereas on the right, the arm and chest were prepped and placed on a sterile Mayo stand. And this just kind of highlights the differences as certain surgeons prefer to have a full arm table, others are able to work on a Mayo stand, there's no right or wrong answer. Some would argue that it's a bit more efficient to have everything in the field and not do position changes. When you're moving the flap from the back towards the arm, you have to make sure that you obviously have a general tunnel. And I like to Doppler the pedicle to make sure that there isn't any kinking. And here you can see the flap inset with a split thickness skin graft. And in this particular patient on the right, a skin paddle was taken and there was inset and monitoring capabilities of the skin paddle. One of the most important things with the latisse flap is the donor site management. Typically, I'll use one to two drains. More recently, these incisional vacs have really changed the management of these patients. The companies are very, very friendly and amenable to helping you troubleshoot these devices, but pretty much they're set up to be used for up to seven days. And the purported benefits are decreased seroma rates as well as the dehiscence and they can be removed in the office or in the inpatient setting if a patient is still in the hospital. And the last flap I'll discuss is the groin flap. This is a patient that had a multi-digit amputation with significant soft tissue loss. And in order to preserve length, we decided to perform a groin flap, the usual markings of the ASIS and pubic tubercle and the femoral artery and superficial circumflex. Important point here is if you're going proximal, excuse me, medial to the sartorius, you wanna transition to a subfascial planes to preserve your pedicle. In addition, if you're using this to reconstruct multiple digits, you may need to quote unquote syndactylize the digits and you have to let the patient know that a second and third operation are required. The second operation to divide the patient from the groin, the third operation to separate the digits from themselves. So in conclusion, you wanna assess the donor sites for scars and possible injury to the pedicles of interest. I like to simulate transfer when possible. That includes using a computer, iPhone, gloves, drapes. I prefer opening the adjacent tissue, but you can tunnel just as long as it's generous and not compressive. Loose closure is recommended so that you don't cause ischemia of the flap. And then splint versus soft tissue dressing is based on patient and surgeon factors. Thank you. Thank you very much, Dr. Huber. Excellent overview. And thank you for going through so many sort of a workhorse operationality flaps for us. We did have one question from the attendees is whether we recommended, the panelists recommended obtaining preoperative angiograms prior to scheduling for radial forearm flap. And this can be set for free flaps or pedicle flaps. Dr. Huber, do you have a particular answer to this? I don't routinely get angiogram for reverse radial forearm flaps. I kind of use the clinical exam, and I also confirm intraoperatively. I'll use angiograms if I'm considering a free flap, both harvesting, more so for looking for recipients in the area, but in general, I don't use it for the reverse radial. Yeah, I completely agree. I think I usually, if I know I'm just sticking with a pedicle, if I have an Allen's test that's showing a circumference arch that's intact, then I'll proceed without further imaging. I certainly will do imaging if it's sort of a highly injured, traumatized upper extremity, and I'm still sort of considering all options. So that sometimes I will obtain it, but it's not a requirement or recommendation. I think I agree, Dr. Hooper, clinical assessment intraoperatively, and I'll certainly, even beyond just looking at blood flow or cap refill, I'll pull out the Doppler and Doppler each distal phalanx as my exam while compressing either the radial or ulnar artery to really get myself a sense of the sufficient profusion to the upper extremity in the hand. All right, any other questions for now? If not, thank you for the questions, keep them coming, and we will move on to Dr. Heather Baltzer for her presentation, our next presentation, and Dr. Baltzer's representing the Canadian contingent from University of Toronto. Dr. Hooper, can you stop sharing on your screen, and then we'll let Dr. Baltzer share her screen. Sorry, I didn't want to show too much Michigan football stuff. All right, good evening, everyone. Thanks so much for inviting me to be on this panel, and all the talks have been really excellent, and I've learned a lot so far tonight. I've been tasked with speaking about microsurgical soft tissue coverage in the upper extremity. Why won't that go ahead? I have no financial disclosures for this evening's talk, and I've been asked to cover a lot of things, so I might feel like I'm moving in a bit of a whirlwind fashion, so I apologize for that, but with respect to flaps, I'll cover some tips and tricks for preoperative planning and flap selection and inset for fascia cutaneous and pre-functioning flaps, as well as innovations in the preoperative and perioperative setting to help reduce the chances of postoperative complications. So we find ourselves sort of hopping on the reconstructive elevator and heading towards free flaps in a number of scenarios, and we just heard a really awesome talk about, or two awesome talks about how we can use skin grafts or dermal replacement in skin graft, as well as pedicle flaps for reconstruction, but sometimes that's really not possible, or it's a really large defect and we've already used a pedicle flap and we need something else to obtain coverage. In cases when it's not available to use a pedicle flap, such as a reverse radial forearm flap, is the situation where you have an injured arch, which we do in a lot of our traumatized hands, or there's an incomplete arch and that's just the patient's anatomy. Other times is that when we have exposed critical structures like tendons that don't have peritonin or nerves that need to have good soft tissue coverage, or when you have functional transfer that's needed. So this kind of plays into the question that was just asked. I'm actually a big advocate in the setting for a free flap reconstruction to get preoperative vascular imaging, and I think a lot of this is based on that when you have a highly traumatized hand, you can't really have a reliable Allen's test, and so that's why in my mind I feel like it's the safest thing to do this before you embark on a free flap. It also helps you with surgical planning. In my institution, we routinely use CT angiography for this. Some people may use conventional angiography or Doppler ultrasound to evaluate the arch and how patented it is. And this is an example that I'm showing here of a young man, and I'll talk about him later, who had a hand amputation and a replantation and then had loss of the tissue over the replantation sites. We needed free soft tissue coverage, and the radial artery had been repaired. The ulnar artery had not, and so this was just demonstrating the availability of the artery where it sort of could be used in demonstrating that we needed a longer pedicle for this flap. So when we think about the options for free soft tissue transfer in the upper extremity, the list is long and includes fascia cutaneous flaps, musculocutaneous flaps, omental flaps. But really, I would say that I'm a big proponent, and these are the flaps that I'll kind of talk about and touch on tonight, are fascia cutaneous flaps, and my workhorses are the radial forearm flap and ulnar forearm flap, as well as anterior lateral thigh flap. My preference is for fascia cutaneous coverage, and my reasoning for this is that you're really then able to sort of achieve like with like. You're also able to go back more easily in a second stage if you need to do something like a tenolysis, and it has less donor site morbidity. And so that's my preference over using a muscular flap covering with a skin graft. However, sometimes you have a really big defect and you need to put a large latissimus dorsi flap on. So some things to consider when you're kind of embarking upon the stages before doing your free flap is just thinking about what your inflow and outflow will be. And this kind of, again, highlights the importance of having that preoperative imaging in a setting like a hand like this where you can't really reliably do an Allen's test. And so you want to figure out if you need to do an end to side anastomosis, and that would be in a situation where the arch is injured and you don't want to take away flow to or is incomplete and you don't want to take away flow to either the radial or the ulnar digits. Or if you can use an end to end anastomosis in the setting that I just showed, you have to think about the zone of injury and how long your pedicle needs to be. So in this hand on the side here, we would assume that we would need quite a long time assume that we would need quite a large pedicle to get out of the zone of injury. And you also want to think about what your venous outflow will be, because sometimes there isn't going to be an awesome cephalic vein there to accept your free flap. Then you need to think about what you need the flap to do. So how big is the flap that you need and where is it going to be? So, you know, if it's going to be covering a thumb or covering the palm of a hand, that's when you really want something that's going to be much more thin, replacing that leg with an ideally giving you sensory function to improve the function of the hand. You also want to think about the donor site and considering the BMI of the patient is really important, particularly in something like an ALT flap or a lateral arm flap, where it could end up being something that's quite thick that you're putting on the upper extremity and will end up looking like a big piece of cake. The contralateral side, if you're harvesting from there, then you want to think about the continuity of the arch. Usually you can rely on an Allen's test for this as well as we were just discussing, but sometimes you may feel like you need to get additional imaging as well. So we'll go back to this case, the young man that had the hand replantation. So we can see that there's pretty much near circumferential loss of his hand. And so we are around the wrist and covering the critical structure. So we kind of ask ourselves, what do we need this flap to do? We need it to be thin and pliable. So it can actually go pretty much all the way around the wrist. And that helps to sort of dictate the kind of flap that you need. If you tried to put an ALT on here, that's relatively thick, you'll need a really, really large flap because you're going to lose a lot of that flap, just getting it to contour around the wrist. You also want to think about what vessels are available. We talked about how the radial artery had been repaired and the ulnar artery was available for use in that we had a large zone of injury. So that artery was actually kind of farther back. So you need to consider that in terms of your pedicle length. So for this patient, we used a contralateral radial forearm flap that was quite large, but it allowed for a nice soft tissue coverage over this area and enough pedicle to get out of the zone of injury. We also were able to identify the cephalic and go into the cephalic from the radial forearm flap into the cephalic in the forearm. And one of the things that I like to do for these, because we were talking about closure earlier and how we want things to be tension-free, and that's really important over your pedicle. And so what I like to do, particularly in settings like this, where it's a circumferential incision around the limb and over the pedicle, I like to raise a little transposition flap or somewhat large transposition flap and just make sure that this is plopped over your pedicle in a tension-free manner, and then just skin graft the back cut so that you don't have any tension over your pedicle. The other flap that I find myself using more and more in my practice is the ulnar artery flap. And this is an example of using this. So this was a young man with a crushed avulsion injury to his right hand. And if we go back to the question of what do we need this flap to do, in this hand, what we really needed was soft tissue coverage over the thumb. He'd had amputation through the neck of the metacarpal, so the intrinsics were able to cover the bones, and he was able to have skin grafting over the rest of it. We really needed something that would give sensate coverage over the thumb. Imaging didn't show that he had continuity of his arch in this situation, so doing any sort of reverse radial forearm flap was not a possibility for coverage. And we examined his left hand. He was radial dominant, and so an ulnar artery flap seemed like the option that was the best. And just like what we were just talking about, I think it's really important, even if you have a relatively normal Allen's test, you always want to go in and just put a clamp over your vessel and ensure that there's good vascularity. Let the tourniquet down for five minutes. Make sure that there's good blood flow to the hand, and you're not going to compromise that, and you're not missing anything. One of the reasons I really like ulnar artery flaps is that this is a nice thin flap. The donor site is less conspicuous than what you have for a radial forearm flap, because it's sort of on the posterior aspect, or I guess the medial aspect of the forearm. It has less hair, usually, than a radial forearm flap, and it has a nice long pedicle, and you can take advantage of sensory capacity with this flap. So in this setting, this flap fit really well into this don't defect to cover the thumb, and I was able to hook this up to the ulnar digital artery into the medial interbrachial cutaneous nerve to try and make it sensate. And again, I'm just showing what I like to do of elevating this transposition flap to plop it over the pedicle that was going into the radial artery in the snuff box, and just skin grafting where the back cut is for that transposition flap. And here's this patient at one year follow-up. He felt that he had reasonable sensation in his flap, and he was using it for pinching and playing video games, and he was pretty happy with the outcome. So then we get into situations where we have larger defects, and this is a 65-year-old male who had multiple debridements for a necrotizing fasciitis in his upper extremity. He had a large palmar defect with exposed critical structures, and this went into the web space. And so again, we think about what we want our flap to do here, and really the key things that we need the flap to do is give this palmar coverage and make sure that the web space doesn't contract and cover the critical structures in the palm and the volar forearm. So we need something that's relatively large, ideally something that has sensate capacity given that we're reconstructing the palm. And the rest of the defect, you can kind of break down into something that would be amenable to skin grafting, and that's what we did. One of the things in this case is that the CTA, again, not a hand that we could do an Allen's test on, so did a CTA, and it showed an incomplete arch. And so the ulnar digits were being perfused by the ulnar artery and the radial digits by the radial artery. And so this is a situation where we could not do an end to side. And so because this patient was thin, this was an appropriate example to use an ALT flap for giving good soft tissue coverage. We use the lateral femoral cutaneous nerve into the palmar cutaneous branch of the median nerve for sensation. And then in terms of hooking this up vascularly, we went end to side into the ulnar artery. And as you can see, there weren't a lot of really great veins to use in this situation. So we use the two VCs for vena comatant from the pedicle in the flap going into the vena comatant around the ulnar artery, and then using skin graft for the remaining deficit. So now we'll shift gears and talk about free functioning muscles. And so I think with this, usually you're doing these cases in a very kind of elective setting, obviously to restore critical function, but you're not having to do it in a trauma setting. So you have some time to do a bit of preoperative workup. This is a young man who had a near arm amputation and had avulsion and loss of his elbow flexors. He also had a brachial plexus injury. So we initially did a brachial plexus reconstruction around the shoulder, and then later on did every functioning gracilis powered by his lateral cord. And so those are things that you take time to work up to that. You don't have to do it right away. So if you're working with a hand, then you can use this time to restore the passive range of motion preoperatively. You can do your vascular workup to ensure that there's good vascular supply and any electrodiagnostic workup that you may need to kind of figure out which part of the nerve may be available for you to use to power these types of flaps. You can also medically optimize the patient if there are any concerns in that manner. So just a few considerations in terms of inset for these types of flaps. You want to make sure that your muscle position is okay. And usually what you want to do is basically mimic the anatomic position of where the muscle would have been. So in the forearm for finger flexion, you want to attach this to the lateral, sorry, the medial epicondyle. For extension, you would want to attach it as insertion into the lateral epicondyle. And for biceps or elbow flexion, you would want to attach this into the acromion. It's important to reduce the bulk around the free functioning muscle that you're insetting. So often this involves debriding any necrotic or non-viable tissue in the area, taking great care to make sure that you protect any of the vascular or nerve structures in the region. You want to have strong motor input for these flaps so that they can have adequate power to drive their excursion. And so in the setting of Volkman skin structure, that's when you can rely on or try to use electrodiagnostic testing to see if there are any small areas of muscle that may be viable that can demonstrate that the nerve is still viable. But typically you want to try and use your AIN to power for roller finger flexion. For dorsal flexion or extension, you want to use your posterior torsius nerve. And then for elbow flexion, if you have it available, your musculocutaneous nerve. And then the really critical point is getting the correct tension. And so when the muscle is in situ before you've harvested it, it's marking out the marking sutures when the muscle is in its greatest tension, and then putting it into its greatest tension again or set that tension to ensure that you have the muscle inset appropriately so that there will be adequate excursion when they try to flex and extend. So now I'll just talk about some innovations and talk first about intraoperative innovations that have been really important or are becoming more important in helping with pre-flap survival. So one of these is the venous coupler. And I think this is something that most people are probably quite familiar with. It's been around for a number of years now. And essentially this is a system that means that you don't have to hand sew your veins, which is something that obviously is very time-saving in the operating room. It reduces the amount of time that you spend, and it also can reduce the amount of venous complications that can be associated with a venous anastomosis. So this is something that I would say is quite commonplace in most microsurgery practices down to a certain size. The smallest size that you can get for a venous coupler is around one millimeter. So beyond that, it's not really feasible. Another intraoperative innovation that I think is, again, quite commonplace in many microsurgical practices is the use of endocyanin green angiography or SPI. And this really gives you that sort of real-time dynamic assessment of the vascular perfusion of a flap. So if we look at this image on the right, you can see there's a flap that's been raised. It hasn't been detached yet, and it has good flow to the central portion, but not to the periphery. And then after flap warming, you can see that there is good flow to the rest of the flap. So if there are areas where there isn't good flow, then you might consider doing a debridement, a removal of that flap, a portion of the flap, because it doesn't have that sort of... or there's perforator insufficiency in that area. So with this technology, you can kind of help to identify complications pre-operatively. And it's thought that this can help to reduce partial flap necrosis and to reduce the rates of exploration. And then we think about post-operative monitoring. You have your flap that looks healthy at the end of the case, and then we get to the middle of the night when it starts to look like this. You obviously want to identify these issues, whether it's a venous insufficiency or an arterial insufficiency, as early as possible so you can try and salvage your flap. And so really the cornerstone of this is clinical assessment. And this, in an ideal setting, is done in sort of a dedicated microsurgery unit where you have nurses that have microsurgery training and know how to... or not microsurgery, but know how to take care of pre-flaps or in an ICU setting where it's feasible to have hourly checks for the first 24 hours, and you have sort of a one-to-one nursing ratio. And so the clinical assessment obviously involves looking at the colour of the flap, checking for capillary refill, the temperature of the flap, and then using external Doppler to assess for that signal that you've identified in the OR. However, this is an ideal setting. Sometimes clinical assessment is limited due to certain circumstances, such as buried flaps or in certain skin tones that may be difficult to identify when a flap is starting to go downhill early. And so that's why there's been a really big movement towards more innovations in post-operative monitoring. And I think as we see more and more technologies that are including artificial intelligence and machine learning, we'll see really an explosion in these kinds of technologies. I think something that's quite commonplace, not in my institution, but I think in a lot of institutions in the United States, are implantable Doppler systems where you actually have the Doppler around the vascular anastomosis, and it gives you that sort of real-time feedback about what's happening with the vessels. Another non-invasive option is something called bioptics, which is placed on top of the flap. It's an external device, and this takes into a number of different parameters, such as the temperature of the flap, as well as the oxygen content in the flap, and can kind of put this information together to give you a sense of what's happening with the flap, and you can get this information in real-time to one of your devices, which is pretty cool. We also don't have that in Canada in our universal healthcare system, but I think that using these and integrating these postoperative monitoring systems can really be helpful to give more reliable detection of flap failure in an earlier time frame, and hopefully give better salvage rates. I think that this is going to be a really interesting area to watch evolve over the course of time. For example, with some of these implantable Doppler systems, rather than having a wire that you have to worry about detaching and possibly injuring the vessel later on, there are some Wi-Fi systems that are coming out and things like that. So I think there's going to be a lot of really cool innovations in this space. So I think that's all I'm going to cover today. Thanks very much again for the invitation and your attention, and I have my email address there if you have any questions, and I'll stop sharing my screen. Thank you, Dr. Baltzer. That was exhaustive. It's wonderful to cover all that, and there's just so much to microsurgery and probably why there's a microsurgery fellowship available for those of us who want to delve more into it. So thank you for covering so much for us in such a little time. Just to keep on with the time, I'm going to go ahead and introduce Dr. Angela Wang, who is a professor at the University of Utah, and she's going to review some tips and tricks for the revast representation of upper extremity and digits. So Dr. Wang, if you can share your screen, and I'll save all the questions that are being asked to the end for our panelists. Thank you for asking questions. Okay. So can you all see that all right? Sorry. The sun has changed, so I'm going to just switch my position a little bit. So thank you for the opportunity to be a part of this. This is a really fun and fabulous panel that you've put together, and my topic is going to be on replantation. So these are my disclosures. So I just wanted to start by talking about some of the trends of replantation, and I will say that I think the trends move fairly slowly in this field. In the 1960s, that's when the first successful replantations were done, and then I think there was just a couple of decades where people were really excited about the possibility of doing that as a new technique, and it wasn't really until the 1980s that we started to see some refinement of the indications. And these are largely the same as they've been since that time, and I think most of us are familiar with these. On the left, you have the indications for replantation, and on the right, sort of relative contraindications to replantation. And then I think the next sort of focus of replantation was about the 2010s, and this was more a focus on, well, okay, so we can do these, and we sort of know when we should do these, and then the next question is, who actually is doing these? So around this time, there's a lot of focus on possibly centralizing replantation centers. A lot of hand surgeons were not terribly excited about doing replantation due to the cost, both to the surgeon and to the hospital, and maybe some dissatisfaction with results. This is a paper from Kevin Chung looking at hospital volume and successes of digital replantation, and they reviewed about 3,000 amputations, of which about 600 or 18% were replanted. Hospital success rate was 70%, and that's sort of a number you're going to hear again and again as to a benchmark of success, and they found that, indeed, higher volume hospitals better achieved this 70% success rate, but high volume wasn't really high volume. You needed to do about three replants a year to achieve that, and I'd say most of us who do replants probably do more than three a year. So then what I want to focus on in this talk is, once you've decided that you're going to put it on, what is the best way to keep it on? And I should have added keep it on alive as opposed to black and necrotic. So we're just going to review some of the latest data supporting this, and I just wanted to start with some things that we know contribute to failure. So this is a nice article from 2021 looking at factors associated with early and late failure of replants. This is a single center study, and this was about 284 patients. They also had that 70% success rate with their replants, and they had 18% early failure and 11% late failure, and this wasn't defined by any certain number of days. It was just whether or not they failed while the patient was in the hospital. So the ones that failed in the hospital were early, and the factors that were associated with this were a crush injury, if you had to vein graft, if it was a complete amputation as opposed to a revasc, and if you had to use leaching. And those last two factors were also implicated in late failures. So we have some things to focus on here. They did notice that their late failure rate was a little bit higher than previously reported, but it was like 11% as opposed to 9%. So we're going to look at some of these factors, and the first thing I wanted to talk about was timing, and this is preoperative timing. So I think most of us are familiar with the traditional ischemia recommendations of six hours of warm ischemia time and 12 hours of cold, but this is a meta-analysis which looks at further extremes. So they went over 22 studies that were included in this, and these studies had extremes of 42 hours warm ischemia and up to 94 hours of cold ischemia, and what they found is that survival is possible. So even with these long times, but they did note that most articles did not report functional outcomes. And this is a second paper from 2016 looking at predictive factors for survival and replantation, and this is a single center study. This had about 70 patients in it, and the only statistically significant factors they found, which came out in multivariate logistical regression, don't ask me exactly what that means, but the only two factors were less than six and a half hours of warm ischemia time, and those that were done during quote unquote office hours. So I think that leads us to the next paper, which is pretty well known, and this is a single center study also looking at immediate versus overnight delayed digital replantation. So in this paper, any of the replants that came in after 6 p.m. were put on ice and well put on ice after being in a saline, you know, they were properly prepared and put in the fridge and done the next day. And they had close to 600 replants, and about a third of these were done in this delayed fashion. Their groups were comparable in terms of mechanism of injury and comorbidities and such, almost all done by one surgeon, and all of the ones that were done the next day had less than 24 hours of cold ischemia time, and they found that there was no significant difference in success rates, and I think they're better than a lot of us because they had 90% success in both groups. So I think there's plenty of data to support that these can be done in a delayed fashion. So we do do this where we are, not all of us, I would say. I probably don't do it, but mostly just because my schedule isn't set up in an ideal fashion. I think things to think about if you do them in a delayed fashion are, if you do them the next day, you're probably going to end up bumping your colleagues. So are you going to run into the irate neurosurgeon or general surgeon, or more likely you're going to have to bump your own service. So you're going to sort of be angering your colleagues, possibly. We try to mitigate this by starting, if we're going to do it the next day, earlier. So maybe 5.30 or 6 in the morning, as opposed to a 7.30 start, because quite rightly your colleagues are going to say, oh, if this is an emergency, why didn't you do it in the middle of the night? I think the most ideal situation is if you bump yourself, but that requires some forethought. If you are having some control of your schedule, I think it would be ideal to arrange your call day, be adjacent to maybe your admin day, your research day, or even your block day. Because then you have more flexibility. I think for those younger people starting out, or if you're looking for a new job, this may be something you want to consider, just to make your life a little bit easier. How about postoperatively? So once you've decided to do the replant, how are you going to monitor it? So this is me. I am type A. My philosophy is I've spent X number of hours of my life on it, and I just am going to worry about it, and I'm going to look at it, and I'm going to keep a hawk's eye on it. Then my fellows mostly started telling me, oh, well, Dr. Tischer, who's a colleague of mine, doesn't do that. So he is known as the Zen master, but his philosophy is kind of like, well, I gave it my best shot at the time, and obviously, this is for a simple replant. This is not for anything complex, but he's like, I did it the best I could. We all know that the second take back is not as good, and it is what it is, and a lot of the time, the patient does want to go home. They don't want to stay in the hospital for seven days and miss all this work and incur all these costs. So that brings us to the next question. Do you do the full scent? Do you do all these things? I've listed some of them, but probably there's several that I missed. So how much do you helicopter parent this? And I think there's some data to show that you probably shouldn't. So this is one paper, which is a systematic review of replants and cost utility, and what they looked at was 53 studies, and they examined previous existing data on quality, so quality analysis, lost, sorry, quality of life years, lost after replants and amps, and then they devised a cost utility model to see if these were cost effective, and what they found was that cost, inpatient monitoring was cost ineffective after one day for a single digit or thumb, and after two days for multiple digits, and they thought this was primarily because most vascular crises had occurred or started to occur by post-op day three. So once that happens, fewer than 9% of digits who underwent this compromise survived. So we all know that the secondary ischemia time is less, and your take backs are less effective than if you do it the first time. So I think this lends some credence to Dr. Tischer's philosophy. We looked at this clinically. This is a study that we presented at ASSH in 2022, so 100 replants or rebascs. We again hit that 70% success rate. Sorry, this slide has too many words, but basically we found that the length of stay inpatient for both successful and failed digits, if you just look at a single digit, was the same, so it's five days. Multivariable regression showed no association between length of stay and failure, and so overall, my philosophy, where you would keep them in and watch them, did not necessarily translate to improved survival. So when do I do the full send? Thumbs, kids, multiple digits, combinations thereof. So I'll still do it, but I'm slowly learning to let go and maybe embrace a new philosophy. Next, I want to talk a little bit about leeches, because I love leeches. I think they're very cool. We all know that they can ingest up to about 10 times their body weight in blood, and they continue bleeding for hours. This is because they secrete all these things that kind of continue the bleeding after they actually detach. There are some issues, so you can have excessive blood loss, ending up needing transfusion, anxiety on the part of the patient, attachment off the digit. If you have a digit that is kind of sketchy, like sometimes the leech will migrate and attach proximal to your anastomosis, which is not what you want. They're colonized primarily sometimes with erymonas hydrophilia, sometimes with serratia to a lesser extent, so you have to prophylaxe with cipro or Bactrim, and in some cases of drug resistance, ceftriaxone. We have also had some detach and then make a break for it. So this makes for a little bit of messy cleanup if they're leaving a bloody trail across the floor. So what's the update on leeches? These are two fairly relatively new studies. The first paper, Quantified Outcomes for Leech Therapy Applied in Digit Revascs and Replantations, their series was 201 digits, of which about 48 digits received leeches, and what they found is that there were better results if the leech therapy was longer, so longer than four and a half days. And on the right is a paper that reviews other papers, so a systematic study of leeches, so a systematic review, and they found that there was better results if you weaned the leeches after post-update five. So I think this correlates with the time that we know angiogenesis needs. They also remarked that if you have an older patient, this may take longer, but overall, they said there is really no guidelines for this. And so anecdotally, I now leech earlier. My philosophy used to be like, oh, I'm going to hold out, and then kind of when I'm really worried about it, I'm going to start the leeching, and now I kind of think of it as prophylactic, so if I'm even slightly starting to think about the leeches, then I'll just break them out, and I tend to use them for a little bit longer. The next topic I wanted to talk about is anticoagulation. There are several papers, reviews, meta-analyses, and I just chose this one, but they all say the same thing, and that's that there's really no one regimen that is proven superior to other regimens, so you can pretty much choose anything as your thrombophophylaxis. I will say, though, that there is some good data that systemic heparin is a little bit on the outs, and there are several papers that cite this. It doesn't improve success compared to other regimens, and there's also increased bleeding complications, and what I do, and I've done this for years, and it doesn't have evidence because there's no evidence out there, but I thought I would share it and see if it's helpful to anyone. I give a preoperative aspirin suppository, but I put this in this cheek, not the other cheek, so after the patient has their airway protected, you can just tuck this in, and I just like the antiplatelet effect. I feel like sometimes if I'm doing the anastomosis, I can almost see that little clump of platelets just forming as you're working, so I just like to give this ahead of time. Then I give 5,000 units at once of heparin at the time that I release the clamp, and then I will repeat this, for example, if your vein ends up taking longer or your second vein takes longer, you have trainees, because the half-life of heparin is only 60 to 90 minutes, so I will repeat this as needed, and then I keep them on a postoperative baby aspirin once a day for a month, and I realize that's overkill. They probably don't need it for more than a couple of weeks, but I just say a month so that they usually stop it before that on their own before. Then just a quick word on vein grafts. There's not really much new out there. I mean, if you need a vein graft, you need it. I think there's been enough written about if you don't have enough veins or you don't have a vein, for example, in a very distal replant, you can take the fingernail off to aid your venous outflow. I actually take the fingernail off in pretty much everybody. I think that a lot of times I can't get two veins, and I think it also gives the leech somewhere to attach to that works pretty well if, as I said, I'm increasing my leech use, so I just give them a good site to attach to. I do want to mention arterial grafts, and this is a trick that was taught to me by one of my plastics colleagues when I first came to Utah, Brad Wackwell. He's written about this. This is his earlier paper, which I think is the best paper for looking at an arterial graft. Arterial grafts I like a lot better because, as we all know, they're much nicer to sew to. You don't have to deal with that floppy, friable vein. I think most of our colleagues, especially the plastic ones, know about the deep inferior epigastric artery, but he taught me about the superficial inferior epigastric artery, which I really like to take because the patients are supine. It's right there for you. It's easy to prep out. The caveat is it's not present in about 30% of people, so I will look for it first, and if I can't find it, then I'll go for the deep inferior epigastric. I don't use this often. I use this mostly in a salvage case, a take back. The bottom right is a forefinger avulsion that I fixed, failed, took it back with arterial grafts, and ended up only managing to save one finger. But it's a nice thing to have in your pocket, I think, and again, the sewing is much nicer with an arterial graft than a venous graft. And then finally, a quick word on is it worth it. I think many hand surgeons themselves would decline a replantation, particularly if it was just a single digit. This is a study looking, it's a retrospective study, but including about 2000 patients. Out of these 2000 replants, about 300 were deemed eligible for this study, and then they got about 254 included. So pretty good, pretty good rate for that. And they administered a whole host of PROs. So the DASH, Uroqual, Michigan Hand, Cold Intolerance, and they found that their revision amps did not have worse PROs than their successful replant. So they replanted when they could. If it was impossible, then they just did the revision and but they found that their results were similar. All these patients had a minimum of 18 month follow-up and their groups were about two thirds replant and one third amputation. And I just wanted to wrap up with this paper. This is a very old paper. So I don't know that all of you are familiar with it. It's a paper about amputations and hand surgeons, not hand surgeons, just all surgeons. And about half of these people, half of these surgeons lost their digits after becoming a surgeon. So you can see it's a multiple, some are single digits, some are multiple digit. The vast majority were from trauma. 29 surgeons actually felt that the amputation gave them advantage, which I thought was kind of interesting. And then three, only three out of these 183 surgeons actually gave up surgery for their career. And one person who obviously was not a surgeon before decided to become a surgeon because they couldn't do the other thing, which was being a pianist. But a super interesting article. I just encourage you guys to check it out because we all, replantation as we know is a big expenditure on the part of the surgeon, on part of the patient, on part of the healthcare system. So just a little food for thought. Thank you. Awesome. Thank you, Dr. Wang. Great review on this topic. Again, lots of information provided. I'm gonna introduce Dr. Emily Shin, who's from the, our military representative from Madigan Army Medical Center and have her bring up her talk. And again, we have a few questions and we'll address them at the end to allow all the panelists to answer and provide their input for the attendees. All right, Dr. Shin. Great. See if we're gonna make this work. All right. Okay, great. Hi everyone. Amazing talks. I'm so impressed by the work that you all do. Thanks again, Helen, for inviting me to present at this webinar. My talk is largely gonna be about making these marvels of soft tissue reconstruction and also enhanced microsurgery accessible. I have no disclosures other than the standard DHA ones. So basically I'm gonna talk pretty briefly about my favorite composite and potentially not composite flaps, medial thermal condyle flap and the fibula. And then we're gonna get into practice management in terms of how to start microsurgical practice if you're interested, how to improve your practice as far as practical tips and tricks inside your institution. And then also how to maximize your microsurgical volume and your personal microsurgical skills. First, quickly, I know this webinar is about to be, supposed to be about soft tissue reconstruction, but it's hard to talk about soft tissue without a plug for vascularized bone grafts plus many of these grafts come with soft tissue components that are very useful. And so I think I would call this flap, the medial thermal condyle flap, the gateway flap to being a flap surgeon because of its simplicity and versatility, its consistent anatomy and its low donor site morbidity. So, you know, all free flaps out there, I think this one is relatively simple to harvest. Flaps easy because finding the pedicle requires very little dissection. You find the area where the VMO coalesces into the extensor mechanism, overlying the medial thermal condyle. And then if you open the border of the VMO there, you find the large network of the large periosteal vessels overlying your bone graft. They're easily followed proximally to the pedicle. So according to anatomic studies, pedicle is three to 10% for, so not very often found, not by the DGA, but coming off of the popliteal artery via the superior medial genital artery, but still easily found. Then basically you just dissect proximally until you get a long enough and large enough pedicle, usually right off the SFA, but sometimes before you get there. So you can usually have a transverse branch, which is usually traditionally used for the osteocardiologenous flap, like for scapoid proximal pole replacement and a longitudinal flap or branch, which is usually what is used for corticoperiosteal flaps or large corticocancellous pieces. And sometimes the branches are translated in such a way that you have to slightly alter the configuration of the flap being harvested, but this is relatively straightforward because the network of vessels is so amazing. So possible flap components include a corticocancellous flap, osteochondral flap, and also a skin paddle, and theoretical limits of harvest are described by studies on the periosteal perfusion in biomechanical studies. So of course I have records and photos of my first harvest ever. These are also the first MSC harvest performed at my institution, which I will get into a little bit later. These are typically an anastomose and decide into the radial artery and both volarly, even the dorsally placed ones, because I shuttled the pedicle subcutaneously in an arch fashion under the skin over the first source of compartment. So as far as complications of MSC harvest, donor site morbidity, so it's actually not that terrible. It's very great. These complications are not surprising. They include knee pain, in particular anterior knee pain. And of course there's a case report, and maybe now, by now, a few case reports of femur fracture from large harvests. So if you need to harvest a larger piece of bone, or really a longer piece of cortical bone, more reliable, bigger skin paddle, I'd go with a free fibula flap. This flap is based on the perineal artery, as you know, which is also a much bigger artery pedicle than the DGA. But this flap is much more tedious of a harvest, as you can imagine, because the pedicle is deep to the fibula. Like you can't see it until the fibula is halfway out, but you can harvest up to 25 centimeters of fibular shaft, like I said, with a nice large skin paddle. And then also with the FHL and soleus muscles as shown here. You can also do a proximal epiphysis transfer for children. And again, just to note that if you harvest a skin paddle, you potentially might not be able to close the defect primarily, so you'll have to skin graft. Potential fibular harvest complications are listed here. You know, everyone gets donor site pain. But, you know, the most comprehensive collection of fibular harvests comes from literature for hip AVN treatment. And of course, the major complication is great toe flexion contracture, which is not surprising because you're basically removing most of what the FHL originates on. However, you know, there's other subtle abnormalities in ankle dysfunction and things that don't end up undergoing any further operative intervention that do also occur with fibular harvest and are less well quantified and described. So that being said, the meat and potatoes of my talk, practice management. And now that you have seen, trained in, and were inspired by the practice of microsurgery marvels, how can you actually incorporate this into your practice? This is really discussion revolving around my early career experience as a surgeon interested in pursuing microsurgery and not finding myself at a large institution where I was expected to be a microsurgeon on my hand surgery service. So, you know, after fellowship, lucky me, I was assigned to work at Tripler Army Medical Center, even luckier, Dr. Ho Chow was with me in Honolulu in the local area. So we had lots of things to commiserate and celebrate about. You know, when you're young and maybe dumb, you feel like you can accomplish anything like hiking several miles at the top of the stairway of heaven, or, you know, like, so like hiking to the slightly illegal location, it is not easy, but certainly possible to pursue a microsurgical practice in an institution that has a history of doing microsurgery, even if you or your department has not done it. So Tripler Army Medical Center, the pink hospital has a history of plastic surgeons, ENT surgeons, urologic surgeons doing microsurgery. That history comes with a plethora of support staff with the knowledge and experience, and, you know, often more years of experience than you. There's equipment already present and supplies already in existence. There's a microscope that people use already and no works, just micro-instruments. There are people using SPI and people who are familiar with and use phyoptics, and it's already bought, so you don't have to convince anyone to budget that out for you. Importantly, we talked about, a lot of people talked about this earlier, you have a place where there's a history of following post-op monitoring protocols. So you have the ICU with people, knowledgeable on monitoring flaps and using the bioptics and all those things. And then, you know, especially in Hawaii, you have nurses comfortable with leeches and also in Hawaii, like I said, leech babysitters, which literally, it is a requirement in Hawaii, apparently, for someone to sit there from the state, make sure the leeches don't get out and cause some sort of ecologic disaster on Oahu. After seeing Dr. Wang's slide with the escaping leeches, I think I understand more why that is essential. Alternatively, if you are as brave and as amazing as Dr. Helen Hoi Chow, you can start your practice in an institution that has never done microsurgery. In her case, she taught her institution to do microsurgery, starting from zero. So she went from teaching the staff, the names of the instruments and their functions, after she ordered them herself, of course, to full-on dress rehearsals, and then, only then, real cases. You know, it's like looking out the side while climbing Mount Adams and seeing only a steep incline, you know, it seems impossible, but she was certainly successful. And while she was there, gave many patients the opportunity to have wonderful soft tissue reconstructions. So while you're in your institution that doesn't do a lot of microsurgery, the key is here to stress the system so that they become used to you using the microscope a lot. So even if you're not doing a flap, get the scope out to do nerve repairs, then you have fewer situations where you're doing a flap take back and there's multiple drape fails. You know, teach your partners how to use your tools. So for example, one of my partners did a Van Ness Reputationplasty, and we used a spy and had good results and fascination with that. In terms of actually doing the cases, you know, I think that the best thing to do is have a two-team approach. And by two teams, I mean a second, you know, not you and a chief resident, I mean like you and a second adult. And that adult doesn't necessarily have to be a microsurgeon. That person can be someone, should be someone you enjoy operating with and someone that you trust to help you and someone who's interested. You can also, you know, ask for your adults. You could look for your adults amongst microsurgical colleagues outside of the traditional orthopedics and plastics. When I was at Tripler, the head and neck reconstruction surgeon, he also didn't have any microsurgical friends. So he and I did a lot of flaps together, same flaps, different, you know, different, put the flaps in different places. You know, these neck veins are humongous. I don't know what the names of the arteries are, but, or I can't remember what they are, but they're, you know, there's three millimeters. Pretty nice. You can also bring in a second, if you do enough advanced planning, you can also bring in a second microsurgery adult from a different institution. For example, you know, I've gone to help some of my former colleagues with, you know, at different military institutions. And then, you know, sometimes we get into situations where we can meet as old fellows and work together. Other things to think about are, you know, it seems to be a huge, long, all day affair at many places, especially if you're doing everything sequentially. And I'd like to think about these long cases as three to four small cases, you know, with no training, three to four small cases, you know, with no turnover. So you get the room excited about that. You know, first you have your exposure of your recipient site. That's case one. And then case two becomes flap harvest. Case three becomes flap inset. And then case four becomes microsurgery. You know, it's just like a regular day. And, you know, and if you have two adults, if you truly have two adults who are comfortable with microsurgery, you can turn this into simultaneous cases and it will seem exponentially less mentally taxing. So you can obviously have someone expose the recipient site while the flap harvest starts and things like that. Other quick things to just mention that will make things seem easier and more feasible. You know, Dr. Balzer talked about using gang couplers. You know, I think that has become standard practice in a lot of places because it makes things very easy. You know, you only really have to sew one thing. So, I mean, especially obviously if your veins aren't big enough, but yeah, you only have to sew one thing. So it's, and the vein couplers are very simple enough that you can teach your residents how to put them on. You want to standardize your micro-resets. You know, sometimes each service has a different set. So, you know, when I arrived at Madigan where I'm currently working, there was an ENT set, there was a plastic surgery set, there was ortho, micro set, and no one could remember where the vein coupler stuff was. I mean, it was a mess. And things became so much more simple and smooth and went so much more smoothly when we got our heads together and standardized things. So when the tray came up, we knew everything was there. The other thing to do is, you know, remember the old Ackland classic microsurgery videos? You can definitely find those. And I would watch those, review those, especially if you haven't done microsurgery in a while. And usually you want to, because they're very dry, enjoy them with a glass of wine or two. Okay, lastly, I just want to touch on, you know, things to do to increase your volume of microsurgery cases. Like I mentioned before, you know, you want to become friends with the microsurgeons in your different departments. You want to make yourself available to help them with their cases. And that way you get more flat purpose, you get more microsurgical anastomosis. You want to form relationships with colleagues who have interest in your skills, people who have holes and things that you want to fill, you want them, who wants you to help them fill them, like trauma surgeons, tumor surgeons. Still looking for the tailors with MF, that I can put an MFT in, but you know, your foot and ankle surgeons. And then also, you know, your very best friend, the orthopedic infection expert. Then, you know, find a few flaps you really love and use them to gain experience. I, some people say, you know, everything is a X, whatever flap you like, shape hole that you can see and tailor. And then finally, accept challenges and don't be afraid to contact mentors who have more experience than you. Could be mentors like Ian Valerio, for example, who I found answers his phone even at 11 p.m. Or your colleagues who, you know, have done whatever case you have a question about more frequently than you. There are a lot of people out there who are willing to provide mentorship and answer questions and give suggestions. And then finally, really, you know, think about how much you love microsurgery. And again, you know, it's the love of doing amazing things that for patients that really, I think really helps drive you and motivate you to do more and to make it work for you. And, you know, especially if you're in an academic institution where you have residents and trainees, think about how, you know, you're going to be a mentor someday or how you are a mentor and how you want to pass your love of microsurgery on to the next generation. Thanks, that's all I have. Any questions and comments? We'll direct to Dr. Hoi Chau. Thank you so much, Dr. Shin, appreciate it. That's such a great overview and talk and thanks for all the props. I'm not sure I'm worthy of all of them, but it's definitely good to see your strategy and building microsurgery coming from an orthopedic background. So I'll quickly, sorry for running over time. This is what happens when you have several microsurgeons talking about their passion and what they love to do. So in the meantime, I will put up how to, again, claim your CMEs while we're talking about the questions. But we had one question that was discussing about a concern for Steele syndrome. If you're doing a free flap end to side in the upper extremity in a one-armed extremity. And so I'm assuming that you're speaking about either an injured radial or ulnar artery and you have only one of the other ones left. So for that, Dr. Cabreo, I typically utilize the injured artery proximal stump as my inflow, even if it is so proximal that I need to use a vein graft instead of risking injuring the uninjured single vessel form by an end to side anastomosis. And so in doing that, I have luckily not had any issues with any difficulty with perfusion of the remaining hand. And then if you're speaking more proximally in terms of the brachial artery, I have definitely done end to side on that. And I find that the flow is so robust and especially going into free flaps are usually no larger than about three to four millimeters in size for their arterial anastomosis that there's not, I've not, again, not going to have any complications with distal extremity perfusion. I hope that answers your question. The panelists have anything different or any other advice on that? No? I've done the end to side in the leg often with a single vessel leg and I've not had problems with Steele syndrome. Yeah, perfect. Great, well, I want to thank the faculty again for their time in presenting such great overviews of such a interesting and sometimes complicated topic as about soft tissue reconstruction of the upper extremity and also being tasked with talking about innovations and new tips and tricks. Again, this is how you claim your CMEs. Let's see, and since we're over time, if we don't have any further questions, any other comments from our faculty? Then, yeah. Well, thank you very much, faculty, and thank you for all the participants, attendees for joining us and asking such interesting questions as well. Thank you. Good night. Thank you. Thank you. Have a good night.

soft tissue reconstruction

skin grafting techniques

upper extremity wounds

dermal regenerate templates

Resel

split-thickness skin grafting

full-thickness skin grafting

bolstering skin grafts

donor site dressing

negative pressure wound therapy

fibrin glue

Mepilex AG

microsurgical soft tissue coverage

free flaps