Imaging Modalities for Evaluating Lymphedema.

Lymphedema is a progressive condition. Its therapy aims to reduce edema, prevent its progression, and provide psychosocial aid. Nonsurgical treatment in advanced stages is mostly insufficient. Therefore-in many cases-surgical procedures, such as to restore lymph flow or excise lymphedema tissues, are the only ways to improve patients' quality of life. Imaging modalities: Lymphoscintigraphy (LS), near-infrared fluorescent (NIRF) imaging-also termed indocyanine green (ICG) lymphography (ICG-L)-ultrasonography (US), magnetic resonance lymphangiography (MRL), computed tomography (CT), photoacoustic imaging (PAI), and optical coherence tomography (OCT) are standardized techniques, which can be utilized in lymphedema diagnosis, staging, treatment, and follow-up. Conclusions: The combined use of these imaging modalities and self-assessment questionnaires deliver objective parameters for choosing the most suitable surgical therapy and achieving the best possible postoperative outcome.

"Double Barrel" Lymphaticovenous Anastomosis: A Useful Addition to a Supermicrosurgeon's Repertoire.

Microsurgical amelioration of lymphedema has gained much traction in recent years and is now an established modality of treatment for this condition. Despite the development of many newer techniques, lymphaticovenous anastomosis still remains the most frequently carried out microsurgical procedure for lymphedema. One of the most common hurdles faced by lymphatic surgeons while carrying out a lymphaticovenous anastomosis is a mismatch in sizes of the vein and the lymphatic vessels. Method: This article describes a novel but simple "double barrel" technique, developed by the authors for carrying out lymphaticovenous anastomosis in cases of such lymphaticovenous mismatch. Seventeen double barrel anastomoses were carried out in 12 lymphedema patients, over a 4-year period from 2017 to 2021. Results: The overall success rate was 100%, as measured by clinical observation (venous washout, lymphatic backflow), the Acland vessel strip test, and by means of intraoperative ICG lymphography. Mild leakage was observed in four cases after release of the venous clamp and was corrected by application of additional sutures. Conclusions: The double barrel technique is a safe and effective tool that can be employed to deal with the bane of size mismatch, a persistent problem faced by lymphedema surgeons universally. Although we do not advocate it as a total replacement for other techniques, it can be a worthy addition to the present set of available options. In specific scenarios of mismatch with additional challenges, the double barrel technique has the potential to be considered as primus inter pares.

Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis.

BACKGROUND: Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. METHODS: Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. RESULTS: Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. CONCLUSION: High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.

[Thoracodorsal artery perforator fasciocutaneous flap in the treatment of chronic hidradenitis suppurativa of axilla]. / Az arteria thoracodorsalis perforátor fasciocutan lebeny a krónikus axillaris hidradenitis suppurativa kezelésében.

BACKGROUND: The only definitive treatment of chronic axillar hidradenitis suppurativa (HS) that prevents relapses is 'in toto' excision of the infected glandular tissue. This way a deficiency emerges, which needs to be restored. Reconstruction with split skin graft (SSG) is a most common way of recovery, but thoracodorsal artery perforator (TDAP) fasciocutneous flap delivers better functional and aesthetic results. METHOD: Between May 2014 and July 2016, 14 patients underwent reconstructive surgery after excision of axillary HS, 2 of them had bilateral lesion. In 15 cases TDAP was used, in 1 case we used thoracodorsal artery capillar perforator flap (TAPcp). RESULTS: In all but 2 cases 1 dominant perforator was found. 1 flap had 2 dominant perforators and 1 flap was supplied by capillary perforators. Size of the flaps spread between 6 × 8 and 10 × 15 cm. 15 reconstructions were successful, 1 flap necrotised because of the lack of compliance of the patient. CONCLUSION: As a result of the glandular tissue excision carried out because of a chronic HS, a deficiency emerges. TDAP flap is an ideal solution for surgical reconstruction of axillar deficiencies, and a great alternative to SSG.