Superficial-Temporal-Artery-To-Middle-Cerebral-Artery Bypass in Cerebrovascular Occlusive Disease and Hemodynamic-Related Ischemia: Illustrative Case and Literature Review

Stroke is the third most common cause of death worldwide. About 10% to 15% of strokes related to the territory of the carotid artery are associated with its complete occlusion. There is an important subgroup of patients with cerebrovascular occlusive diseases who might benefit from an external-carotid-to-internal-carotid bypass. In the present study, we report a case of a 53-year-old male patient with stenosis of the M2 branch of themiddle cerebral artery (MCA), with a history of 20 episodes of transient ischemic accidents (TIA)s, in whom an anastomosis of the M4 branch of the superficial temporal artery-MCA was performed. The patient was discharged in three days, and in the two years of follow-up, they were no more TIAs.We also conducted a review of the literature on cerebrovascular occlusive disease and extracranial-intracranial bypass surgery. New methods to evaluate cerebral hemodynamics made it possible to classify a new subgroup of patients with symptomatic cerebrovascular disease and documented cerebrovascular compromise in whom the drug therapy fails, who can benefit from the extracranial-intracranial bypass. Our case report illustrates the advantages of revascularization in these selected patients.

Technical difficulties and key points of DIEP in breast reconstruction / 中华内分泌外科杂志

Surgical treatment is an important part of comprehensive management for breast cancer patients. Loss of breast will bring serious psychological trauma to patients and greatly reduce the quality of life. In autologous breast reconstruction, deep inferior epigastric artery perforator flap (DIEP) -a representative reconstructive technology has its incomparable advantages. The flap has sufficient blood supply. The reconstructed breast has natural contour and texture, and the complications in the donor area were quite low. It is also an important alternative to rescue the reconstructive failures. However, DIEP flap is difficult and has a long learning curve. The key technical points and difficulties not only run through the whole process of operation, but also exist before and after operation. On the basis of mastering the main concepts of DIEP, this paper would elaborate the important details in the operation process and emphasize the monitoring of skin flap after operation and the corresponding plan. This will help to better popularize the operation technique, improve the success rate of operation and patient satisfaction, while reduce operative complications and benefit more breast cancer patients.

The preliminary application of 3-dimensional visual technique without eyepiece in repairing breast defect af-ter radical mastectomy in 2 cases of breast cancer / 中华显微外科杂志

To investigate the possibility of microsurgical anastomosis of artery, vein and lymphat-ic vessel under 3-dimension screen without eyepiece. Methods During March, 2019, 2 cases (48 and 62 years old) were operated for breast reconstruction, chest wall deformity modified, and axillary scar contracture release, under 3-dimension screen without eyepiece.Deep epigastric artery perforators (artery and vein) dissections were carried on, and microsurgical anastomosis of artery, vein and lymphatic vessel were finished. Coupler was used to do the end-to-end anastomosis of veins (2.5 mm), interrupted suture end-to-end anastomosis with 9-0 nylon for artery (2.0 mm). Reverse arm lymphatic dynamic fluorescence methylene blue tracer under Near Infrared Imaging was used to test the func-tion of lymphatic system. The ends of 2 dominant drainage lymphatic vessels was found in the released axillary area (0.2 mm and 0.3 mm, respectively), and were anastomosis to the vein (0.5 mm) of lateral chest lymphatic tissue.Im-mediate methylene blue tracer under near infrared imaging was used to confirm the patency of lymphatic vessels-veins anastomosis and follow-up post operation. Flap were monitored use HHD. Results Two patients recovered well, and the flaps survived completely with appreciated appearances. The lymphedema of the arms were getting better, the peripheral diameter was reduced by about 2.0 cm compared with that before operation. Conclusion The technique of microsurgical anastomosis of artery, vein and lymphatic vessel without eyepiece under 3-dimension screen is possi-ble and safe.

Colgajos Microvascularizados en Reconstrucción Maxilofacial: Avances de la Microcirugía / Microvascularized flaps in Maxillofacial Reconstruction: Advances in Microsurgery

RESUMEN: La reconstrucción de la cabeza y el cuello contempla avances importantes a lo largo de los años. Los colgajos microvasculares se han convertido en la primera opción de tratamiento en grandes defectos del territorio maxilofacial, mientras tanto, la tecnología con el uso de microscopía y luego las imágenes como CT, angiografía por tomografía computarizada, dispositivo ultrasónico, RNM o Doppler contribuyen a lograr una predictibilidad excepcional de estos colgajos microvasculares. Por lo general, la técnica de anastomosis consiste en una sutura de 9-0 en 360°, pero existen autores que han descrito diversos métodos que no son de sutura con un rendimiento aceptable. Existe un buen número de diferentes colgajos microvasculares, cuatro de ellos son los más comunes en la reconstrucción maxilofacial: fíbula, ilíaco, antebrazo radial, escápula. Además el colgajo anterolateral, muy útil en defectos de piel y tejidos blandos. La evolución de los colgajos microvasculares implica los colgajos quiméricos, muy útiles en defectos grandes. El objetivo de este artículo es describir y exponer el desarrollo de la microcirugía y las diversas opciones de colgajos microvasculares en la reconstrucción maxilofacial.

ABSTRACT: Head and neck reconstruction have shown important advances over the years. Microvasculars flaps transfer has become the first treatment option in large defects of the maxillofacial area. Meanwhile technology through the use of microscopy and the subsequent use of images such as CT, CT angiography, RNM or Doppler ultrasonic device, and additional new techniques have contributed to an exceptional predictability of these microvascular flaps. Typically, the anastomosis technique consists in 9-0 suture in 360°, but since the vascular flaps exist, authors have described diverse non-suture methods with acceptable performance. There are a number of different microvasculars flaps, four of them are the most common in maxillofacial reconstruction: fibula, iliac, radial forearm, scapula. In addition the anterolateral tight flap, very useful in skin and soft tissues defects. The microvascular flaps evolution involves the chimeric flaps that are useful in large defects. The aim of this article is to describe and expose microsurgery development and the diverse microvascular flap options in maxillofacial reconstruction.

The clinical significance of delayed double knotting over the entire microvascular anastomotic period for free flap reconstruction / 实用口腔医学杂志

The clinical application of delayed double knotting over the entire microvascular ananstomotic for free tissues transform has the advantages of direct vision and it easy approachs,is useful to avoid the opposite wall biting and other mistakes.It is especially feasible in the management of the cases with endangium denudation.

Comparison of end-to-side and end-to-end microvascular anastomosis in free perforator flap transfer for hand skin and soft tissue defect / 中华显微外科杂志

Objective To observe the survival rate of free flaps and incidence of vascular crisis following the perforator flap transfer in end-to-side microvascular anastomosis compared with the traditional method and investigate the scientificity and practicability of this scheme.Methods From February, 2012 to October, 2013, 152 cases of free flaps (including superficial illiac circumflex perforator flap, lateral arm flap, peroneal perforator flap, and anterolateral thigh flap) were performed.The end-to-side anastomosis were performed in 72 cases while end-to-end anastomosis in 80 cases;All patients were followed up for 6-24 months.The occurrence of vascular crisis in all cases were observed and recorded.The results of the two groups were conducted statistical analyzed.Results The average anastomosis time for end-to-side anastomosis (21.3 ± 3.8 min) was significantly higher than the end-to-end anastomosis (14.4 ± 3.2 min) (P ＜ 0.05).The incidence of anastomotic vasospasm after end-to-side anastomosis (5.6％) was significantly lower than traditional method (16.3％) (P ＜ 0.05).There was no significant difference in the survival rate of the free flaps between the end-to-side anastomosis group (97.2％) and the traditional group postoperatively (96.3％) (P ＞ 0.05).Conclusion Although anastomosis times were increased in the end-to-side group, this technique showed lower spasm rate and similar flap survival rate.Therefore, this technique is a reliable and technically feasible method and should be considered first as a choice when facing vessel discrepancy and for preserving the recipient artery and vein system.

Effect of the training scheme of microvascular anastomosis in different time courses / 中国脑血管病杂志

Objective To investigate the effect of the training scheme of microvascular anastomosis in different time courses. Methods A total of 31 neurosurgeons were trained with different training schemes of microvascular anastomosis with ultrashort time course (n = 9;4 h),medium time course (n =12;12 h),and long time course (n = 10,300 h)were selected respectively,including 22 neurosurgeons from the top three hospitals and 9 from other levels of hospitals. Before training,the average median time of working in a department of neurosurgery was 6 (range,0 to 19)years. After training,the trainees accepted the assessments,such as performing the rat common carotid artery end to end anastomosis under a surgical microscope. Their completion time,anastomosis quality score,and proportion of vascular patency after anastomosis were compared. The measurement data of normal distribution used the single factor analysis of variance. The skewed distribution used rank sum test. The comparison of count data used Fisher exact test. Results The trainees who participated in the ultrashort time course training,the time of completion of carotid end - end anastomosis was 78 ± 37 min,the anastomosis quality score was 8. 1 ± 2. 8,and 2 vessels were patent;the trainees who participated in the medium time course training,the anastomosis time was 69 ± 20 min,the anastomosis quality score was 15. 8 ± 6. 8,and 10 vessels were patent;the trainees who participated in the long time course training,the anastomosis time was 34 ± 7 min,the anastomosis quality score was 23. 5 ± 1. 3,and 10 vessels were patent. There were significant differences in the completion of anastomosis time among the 3 groups of trainees (F = 9. 50,P = 0. 001). The completion time of the long time course group was shorter than that of the medium time course group and the ultrashort time course group. There were significant differences. There were significant differences in the anastomosis quality score among the 3 groups (F = 26. 870,P = 0. 000). As for the number of the patent vessels,there were significant differences between the medium and long time course groups and the ultrashort time course group (P < 0. 01 ). Conclusion If the vascular anastomosis skills of the trainees achieve relative proficiency and stability,they need to choose the long time course training.

The preliminary application of microvascular anastomotic device for free flap transfer in head and neck cancer patients with locally advanced lesion / 中华显微外科杂志

Objective To observe the effect of vein anastomosis by microvascular anastomotic device in head and neck reconstruction.Methods Sixteen cases needing free flaps were randomly selected in head and neck cancer patients with locally advanced lesion.Their veins were anastomosed by microvascular anastomotic device.Other 40 cases whose veins were anastomosed by manual anastomosis were selected as control during the same year.The statistical data of the time of veins anastomosis,thrombosis and the rate of flaps salvage were compared.Results The average time of venous anastomosis was 6.31 ± 0.87 minutes,which was lower than the manual anastomosis (19.20 ±4.62 minutes) significantly.There was no thrombosis,which was not significant different with the manual anastomosis.One case's venous blood flow was not smooth for the angled vein and the flap salvage operation was successful.Conclusion The time of venous anastomosis is shorten significantly by microvascular anastomotic device.The incidence of thrombosis is the same compared with venous anastomoses performed with sutures.The microvascular anastomotic device system allowed a time-efficient and safe venous anastomosis.

Effect of 4-hexylresorcinol on Blood Coagulation and Healing of Injured Vessel in a Rat Model

Anatomical Review of Anterolateral Thigh Flap for the Oral and Maxillofacial Reconstruction

Anatomical Review of Rectus Abdominis Muscle Free Flap for the Oral and Maxillofacial Reconstruction

Anatomical Review of Latissimus Dorsi Free Flap for Oral Cavity and Facial Reconstruction

Anatomical Review of Radial Forearm Free Flap for the Oral Cavity Reconstruction

Classification of microvascular anastomosis in oral and maxillofacial reconstruction

A reconstruction following a resection of malignant oral cavity tumors is one of the most difficult problems in recent oral oncology. For a better understanding of oral and maxillofacial reconstructive procedures, basic and advanced microvascular anastomosis techniques must be learned and memorized. The aim of this article was to clarify and define the microvascular anastomosis methods, such as primary closure after an arteriotomy, end to side anastomosis, end to end anastomosis, and side to side anastomosis with an artery and vein. This review article discusses the basic skills regarding microvascular anastomoses with brief schematic diagrams in the Korean language. This article is expected to be helpful, particularly to young doctors in the course of the Korean national board curriculum periods for oral and maxillofacial surgery.

Clinical Cases Analysis of Forearm Free Fasciocutaneous Flaps on Oral Cavity Defect Area

Gastroepiploic Artery Preservation with Glycerol as a Training Model for Microvascular Anastomosis

PURPOSE: We investigate the possibility of vessel preservation with glycerol and evaluate the potential of preserved gastroepiploic artery as a tool for the microsurgical practice. METHODS: In 5 early gastric cancer patients, IRB(No. C-0603-040-170), we gained gastroepiploic artery specimens(5 segments, about 10cm) after gastrectomy. Each segment was rinsed in a normal saline and subsequently placed in a bottle, containing 50mL anhydrous glycerol (87%). The bottles were refrigerated at 4degrees C, the longest preservation time being 5 months. RESULTS: At first glance, no fragmentation was detected and the surface of vessel seemed mild sclerotic. In histological examination, vascular structures remained intact though preservation with glycerol led to a mild atrophy of the smooth muscle in the tunica media. Especially, we found out the elastic fibers and endothelial lining of the intima were preserved until 5 months. Adequate status for using microsurgical practice was also maintained and leakage test was performed successfully with gentian violet ink. CONCLUSION: Based on the results obtained in this study, the gastroepiploic artery preservation with glycerol as a training model for microvascular anastomosis is a technically very simple procedure and useful for the novice microsurgeon.

Experimental study on the effects of local irrigation and systemic heparin administration on microvascular anastomosis of the rabbit femoral artery with intended crush injury

Use of Human Placentas for Practice of Microvascular Surgery

PURPOSE: Microsurgical exercise has been performed with rat femoral vessels. But, it needs animal laboratory, anesthesia and its keeping facilities. MATERIALS AND METHODS: Ten human placentas were studied for suitability in a microvascular exercise. The size and useful length of vessels were measured, and various microvascular anastomoses were performed. RESULT: The human placenta has many vessels traversing its fetal surface. A variety of sizes are available down to vessels of diameter 1 mm and up to vessels of diameter 6.5 mm (1.0

Ultrastructural study for vein regeneration after microvascular anastomosis in rabbit femoral vein

Free flap transplantation with microvascular anastomosis has been successfully performed by development of surgical technique, materials and postoperative monitoring equipments of flap. But success rate of microvascular anastomosis is influenced by various factors, and failure rate is about 5-10%. The most influential factor for success rate is surgical technique and other factors that influence failure of microvascular anastomosis are ischemic time of free flap, thrombus formation of anastomosis region and vascular spasm. In this study, vascular patency and thrombus formation in experimental micro-venous anastomosis, and endothelial repair were observed with histologic analysis, scanning electron microscopy, transmission electron microscopic examination. The results were obtained as follows: 1. In vascular patency test in 30 minute and 7 days after micro-venous anastomosis with heparin irrigation, all of 12 anastomosis site were good vascular patency. 2. In thrombus formation in 2 weeks group(Experimental I), 2 site of 6 cases were observed thrombus, and in 4 weeks group(Experimental II), 1 site of 6 cases were observed thrombus. 3. In histologic examination, normal vein(Control Group) showed continued internal elastic lamina, well formed thick smooth muscle layer and connective tissue. The group of 2 weeks after microvenous anastomosis(Experimental I) showd locally recovered internal lamina, discontinued internal lamina, disorganized smooth muscle cells and granulation tissue around suture silk. In the group of 4 weeks after micro-venous anastomosis(Experimental II), anastomosis site showed almostly continued internal lamina, disorganized smooth muscle cells and cicartrized tissue around suture silk. 4. In scanning electron microscope examination in 2 weeks(Experimental I) after micro-venous anastomosis, mesh fibrin formation showed near to endothelial cells, and in 4 weeks after micro-venous anastomosis(EXperimental II), numerous blood cells and fibrin mesh formation was seen associated with irregular endothelial cell arrangement. 5. In transmission electron microscope examination in 2 weeks after micro-venous anastomosis(Experimental I), irregular arrangement of smooth muscle cells was seen adjacent to collagenized tissue around suture silk. In 4 weeks after micro-venous anastomosis(Experimental II), denuded venous wall composed of relatively well arranged smooth muscle cells was covered by endothelial cells, but fibroblast cells and foreign body giant cells near to suture silk was remained. From the results obtained in this study, results of good vascular patiency and anti-thrombotic effect of heparin were obtained as a local irrigation solution, and repair of venous endothelial cell was observed in 2 weeks after micro-venous anastomosis.

Characteristics of Training Materials for Successful Microvascular Anastomosis and Preclinical Assessment of The Surgical Skills / 대한뇌혈관외과학회지

The need for microvascular anastomosis is on the increase for the prevention or treatment of hemodynamic stroke or planned major vessel occlusion for the treatment of complex intracranial vascular lesions or tumors. The surgical skill of the microsurgeon is the most important factor for successful microvascular anastomosis. Thus, surgical experience in the laboratory is essential. With a review of the literature, we demonstrate characteristics of several training materials for the laboratory and preclinical assessments of surgical skills.