Current status and prospect of supermicrosurgery in maxillofacial reconstruction / 中华显微外科杂志

Supermicrosurgery is a hot topic in the field of microsurgery and reconstruction. The core concept of supermicrosurgery is precision and minimally invasive, which coincides with the concept of maxillofacial reconstruction. Oral and maxillofacial regions play an important role in aesthetics and function, and the structure of oral and maxillofacial tissues is complex. Various types of flaps, especially vascularised free flaps, are required for the repair of various complex maxillofacial defects. However, at present, conventional microsurgery does meet the requirement of mandibular reconstruction in special cases. Super microsurgical technique can further supplement the deficiency of conventional methods of repair and reconstruction in maxillofacial reconstruction. Under the guidance, many new methods of maxillofacial surgery have inevitably emerged. The application of supermicrosurgery in maxillofacial head and neck is still in its early stage, and there are still many difficulties to overcome and many technical issues to be furtherresolved. Supermicrosurgery is not only an advanced technique, but also an advanced concept in surgery. Supermicrosurgery is expected to show its clinical value in oral and maxillofacial reconstruction. In this paper, the application of supermicrosurgery in maxillofacial reconstruction is reviewed and its application prospect is prospected.

Tratamiento supermicroquirúrgico del linfocele inguinal con linfedema intercurrente: restauración de la fisiología linfática / Supermicrosurgical approach to inguinal lymphocele with lymphedema: restoring the lymphatic physiology

Resumen Introducción: El linfocele es una patología que puede ocurrir por la disrupción linfática durante una cirugía, siendo frecuente luego de una linfadenectomía inguinal. Existen diversos enfrentamientos para prevenirlo o minimizarlo, sin embargo, los resultados son inconsistentes. Caso clínico: Reportamos el caso de una mujer, con linfocele recurrente en zona inguinal derecha y linfedema distal de la extremidad secundario a una biopsia ganglionar, tratado exitosamente mediante supermicrocirugía para restaurar el drenaje linfático. La extremidad inferior tenía un exceso de volumen de 7,03%. Se realizaron estudios preoperatorios con linfografía por resonancia magnética y linfografía con verde de indocianina para identificar los vasos linfáticos y realizar anastomosis linfático-venosas (ALV). Se identificaron tres vasos linfáticos aferentes y se realizó una capsulectomía total. Se realizaron tres ALV término-terminales supermicroquirúrgicas en zona inguinal y una ALV distal en pierna. Durante seguimiento no hubo recidiva del linfocele, evidenciándose una reducción del exceso de volumen de la extremidad afectada de un 105,26%. El linfocele inguinal y linfedema pueden ser tratados exitosamente mediante supermicrocirugía, restaurando el flujo linfático de manera fisiológica, evitando la recurrencia de linfocele y mejorando los síntomas del linfedema.

Introduction: Lymphocele may occur after the disruption of lymphatic channels during a surgical procedure. After inguinal lymphadenectomy are very common, and many different approaches have been tried to prevent or minimize the formation of lymphoceles with inconsistent results. Clinical Case: We report a case of a female patient who presented with right recurrent inguinal lymphocele and lower limb lymphedema after lymph-node biopsy that was successfully treated with lymphatic supermicrosurgery restoring the lymph flow. Lower extremity had an excess volume of 7,03% compared to the healthy contralateral limb. Preoperative study with magnetic resonance lymphangiography and indocyanine green lymphography were done to identify intraoperatively lymphocele afferent and distal lymphatic vessels to perform lymphovenous anastomosis (LVA). Three different afferent lymphatics were identified and total capsulectomy was performed. Three end-to- end supermicrosurgical LVA in the groin and one distal LVA on the leg were performed. The surgery was uneventful, and there were no postoperative complications. In the follow-up, no lymphocele was noticed and lymphedema had visibly reduced with a reduction of excess volume of 105.26%. Inguinal lymphocele and lymphedema can be successfully treated with supermicrosurgery since it is a physiological approach to restore the lymphatic flow, in order to avoid lymphocele recurrence and to improve lymphedema symptoms.

Linfedema asociado al cáncer de mama: factores de riesgo, diagnóstico y tratamiento quirúrgico / Breast cancer related lymphedema: risk factors, diagnosis and surgical treatment

Resumen El linfedema asociado al cáncer de mama es una de las complicaciones más subestimadas y debilitantes del tratamiento de esta entidad. Ocurre como resultado de la interrupción del flujo linfático en asociación a otros factores. La incidencia varía dependiendo del tipo tratamiento recibido, existiendo mayor riesgo en los casos en los que se realiza mastectomía total, disección axilar, radioterapia, y en los pacientes en los cuales los ganglios están positivos para cáncer, hubo una mayor cantidad de linfonodos resecados, se utilizaron taxanos o padecen de obesidad. El diagnóstico clínico y a través de técnicas de imágenes es fundamental para evaluar el estado funcional del sistema linfático. Los objetivos principales en el manejo del linfedema son limitar la morbilidad del paciente, mejorar la funcionalidad y la calidad de vida. Existen procedimientos que buscan prevenir el desarrollo del linfedema asociado al cáncer de mama. Una vez establecido, el tratamiento puede ser conservador y quirúrgico. El tratamiento quirúrgico incluye procedimientos fisiológicos (reconstructivos) y resectivos. El éxito depende de una buena selección de los pacientes y la realización de un tratamiento individualizado. A continuación, se presenta una revisión en cuanto a la incidencia, factores de riesgo, estrategias diagnósticas y técnicas quirúrgicas con énfasis en el tratamiento microquirúrgico.

Breast cancer related lymphedema is one of the most underestimated and debilitating complications of the treatment of this entity. Occurs as result of the interruption of the lymphatic flow in association with other factors. The incidence varies depending on the type of treatment received; being a higher risk in cases in which total mastectomy, axillary dissection, radiotherapy are performed; and in patients in whom the lymph nodes are positive for cancer, there was a greater number of harvested lymph nodes, taxanes were used or in obese patients. Clinical diagnosis and imaging techniques are essential to assess the functional status of the lymphatic system. The main objectives in the management of lymphedema are to limit patient morbidity, improve functionality and quality of life. There are procedures that seek to prevent the development of breast cancer related lymphedema. Once established, the treatment can be conservative and surgical. Surgical treatment includes physiological (reconstructive) and excisional procedures. Success depends on a good selection of patients and the performance of an individualized treatment. The following is a review regarding the incidence, risk factors, diagnostic strategies and surgical techniques with emphasis on microsurgical treatment.

Úlceras del pie diabético: importancia del manejo multidisciplinario y salvataje microquirúrgico de la extremidad / Diabetic foot ulcers: importance of a multidisciplinary approach and microsurgical limb rescue

Las úlceras del pie diabético son el principal factor de riesgo para las amputaciones no traumáticas en personas con diabetes. El éxito de la intervención requiere un completo entendimiento de la patogénesis y una implementación oportuna y estandarizada de un tratamiento efectivo. Es necesario un enfoque multidisciplinario para inicialmente controlar y tratar múltiples factores causantes de la ulceración severa del pie diabético. El desbridamiento, control de la infección y revascularización son pasos clave para la estabilización de la herida y su preparación para una reconstrucción exitosa. La microcirugía y supermicrocirugía permite proporcionar un tejido bien vascularizado para controlar la infección, un contorno adecuado para el calzado, durabilidad y anclaje sólido para resistir las fuerzas de cizallamiento durante la marcha. De esta manera, se puede lograr el salvataje de la extremidad, mejorando la calidad de vida y aumentando la sobrevida.

Diabetic foot ulcers are the main risk factor for non-traumatic amputations in people with diabetes. A succesful intervention requires a thorough understanding of the pathogenesis and a timely and standardized implementation of an effective treatment. A multidisciplinary approach is needed to initially control and treat multiple factors that cause severe diabetic foot ulceration. Debridement, infection control, and revascularization are key steps in wound stabilization and preparation for successful reconstruction. Microsurgery and supermicrosurgery provide a well-vascularized tissue to control infection, an adequate shoe contour, durability and solid anchorage to resist shearing forces during gait. In this way, the salvage of the limb can be achieved, improving the quality of life and increasing the survival rate.

Linfedema: actualización en el diagnóstico y tratamiento quirúrgico / Lymphedema: update in diagnosis and surgical treatment

El linfedema es la acumulación de fluido rico en proteínas en el intersticio, secundario a anomalías en el sistema de transporte linfático. En países desarrollados se relaciona más frecuentemente al tratamiento quirúrgico del cáncer. El diagnóstico clínico y a través de técnicas de imágenes es fundamental para evaluar el estado funcional del sistema linfático. Los objetivos principales en el manejo del linfedema son limitar la morbilidad del paciente, mejorar la funcionalidad y la calidad de vida. El tratamiento quirúrgico es una alternativa cuando las medidas conservadoras ya no son suficientes. Existen procedimientos que buscan prevenir el desarrollo del linfedema y técnicas que incluye procedimientos fisiológicos (reconstructivos) y resectivos que se utilizan cuando el linfedema ya está establecido. El éxito depende de una buena elección de los pacientes y la realización de un tratamiento individualizado. A continuación se presenta una revisión en cuanto a las últimas estrategias diagnósticas y actualización en las técnicas quirúrgicas con énfasis en el tratamiento microquirúrgico.

Lymphedema is the accumulation of protein-rich fluid in the interstitium, secondary to abnormalities in the lymphatic transport system. In developed countries it is more often related to surgical treatment of cancer. The clinical diagnosis and through imaging techniques is fundamental to evaluate the functional status of the lymphatic system. The main objectives in managing lymphedema are to limit patient morbidity, improve functionality and quality of life. Surgical treatment is an option when conservative measures are no longer sufficient. There are procedures that seek to prevent the development of lymphedema, and techniques that include physiological (reconstructive) and resective procedures that are used when lymphedema is already established. Success depends on a good selection of patients and the completion of an individualized treatment. The following is a review article of the latest diagnostic strategies and update in surgical techniques with emphasis on microsurgical treatment.

Breast cancer related lymphedema treated by super-microsurgery / 中华内分泌外科杂志

Objective Lymphedema is a common complication interrupting a large percentage of breast cancer survivors .How to release the breast cancer survivors from the pain of lymphedema remains a question to breast surgeons .The rapid development of the super-microsurgical measurement allows lymphaticovenular anasto-mosis to become a better way to treat breast cancer related lymphedema .Methods We followed a breast cancer related lymphedema case amd offered super-microsurgical lymphaticovenular anastomosis to her .Results The surgery lasted 4.5 h, and contained 11 anastomosis of lymph ducts .Improvement of edema could be seen during the surgery and the measurement of the upper limb became smaller just one day after surgery .Conclusion Su-per-microsurgical lymphaticovenular anastomosis is a safe improvement for extremity lymphedema after mastectomy and it can provide a better prognosis and appearance .

Techniques in Lower Extremity Reconstruction with Supermicrosurgery

PURPOSE: The concept and development of perforator free flaps have led to significant advances in microsurgery. Ongoing developments in perforator free flap surgery are aimed at reducing complications and improving surgical outcomes. The aim of this study was to evaluate the effectiveness and application of supermicrosurgery in free flap surgery. MATERIALS AND METHODS: A total of 267 patients with soft tissue defects of the lower extremity due to various etiologies from January, 2007 to January, 2013. The patients received either an anterolateral thigh free flap (n=83), a superficial circumflex iliac artery free flap (n=152), an upper medial thigh free flap (n=19), or a superior gluteal artery perforator free flap (n=13). Microanastomosis was performed using a perforator-to-perforator technique, either end-to-end or end-to-side. RESULTS: The mean postoperative follow up period was eight months (range: one to 16 months) and flap loss occurred in 11 cases out of 267. All cases of flap loss occurred within two weeks of surgery due to either arterial insufficiency (n=5) or venous congestion (n=6). CONCLUSION: Supermicrosurgery enables the selection of the most efficient perforator for microanastomosis at the defect site. It also reduces the time required for dissection of recipient vessels, and reduces the possibility of injury to major vessels. Microsurgery using a vessel of less than 1 mm has been reported to increase the risk of flap failure; however, using the most advanced surgical tools and developing experience in the technique can produce success rates similar to those found in the literature.

Twisting Effect on Supermicroanastomosis of the Superficial Inferior Epigastric Artery in a Rat Model

Advances in the practice of microsurgery: focusing on free anterolateral thigh perforator flap.

The purpose of this paper was to discuss an overview of the current clinical practice of microsurgery with a specific use of free anterolateral flap as one of the commonest flaps used in reconstructive surgery. A systematic review was performed through all English publication that goes to Pubmed during the period of 1997 to 2006 using keywords: “anterolateral thigh perforator flap.” The studies involved were retrospective case reviews on using microsurgical technique and involves free anterolateral thigh flap only without muscle involvement. Evaluation was done to search the indications, contraindications, area or organ to reconstruct, the cause of defects need reconstructive surgery, morbidities, functional and aesthetic results, techniques in regard of suture material, and instruments. Using 7th edition EndNote program, 230 abstracts were successfully retrieved in term of “anterolateral thigh perforator flap” of ANY FIELD and Boolean logic OR. Fifty six abstracts from many journals matched the criteria. Due to our limitation to get all of those articles, finally, 8 articles from Plastic and Reconstructive Surgery became the resources of this paper. The overall success rate in terms of flap viability is 98% (525 from 535 flaps) with partial necrosis is as low as 2.2% (12 from 535 flaps). Thinning procedure is commonly applied with regards of the thin flap needed. The recipient sites from 8 articles varies and can be any part of the body includes facial, neck, pharyngoesophagus, breast, upper and lower extremity. Four out of 8 papers mentioned functional evaluation and all stated satisfactory to excellent outcome. There are also 4 papers mentioning the aesthetic evaluation. Overall evaluation was mentioned as good to excellent. It is concluded that free anterolateral thigh perforator flap is a well established choice in most soft tissue reconstruction. It can be indicated to any area needed reconstruction especially head and neck, extremity, and go beyond conventional for breast reconstruction. It has also superior result in pharyngoesophageal reconstruction.