Safety and Vascular Impact of Perforator Propeller Flaps during Distal Lower Limb Reconstruction.

BACKGROUND: In distal lower limb defects, the paucity of local tissues dictates a free-flap (FF)-based reconstruction frequently. The propeller perforator flap (PPF) offers a good alternative when the patient or the limb or both are not fit for FF-based reconstruction. Also, in contexts of restricted healthcare resources, armed conflict scenarios, or during pandemics like the ongoing COVID-19 pandemic, PPF is considered a valuable alternative to free-flap-based reconstruction. Additionally, PPFs are less sacrificing in terms of major limb vessels and distal limb vascularity. Yet, the distal lower limb vascular impact for PPF-based reconstruction has not been studied before. METHODS: In total, 23 patients with distal lower limb defects were reconstructed with PPFs. By using U/S arterial duplex, the peak arterial velocity (PA velocity) was measured pre and postoperatively in 15 (65.2%) out of the 23 patients. This measurement was done to the vessel segment distal to the used perforator. RESULTS: An estimated 21 out of 23 flaps succeeded to reconstruct the patients' defects safely and to give all patients stable coverage without further surgeries. Only two patients had flap failure, which was managed successfully through additional reconstruction sessions. The difference between pre- and postoperative PA velocity was not statistically significant. CONCLUSIONS: PPFs are a safe cost-effective reconstruction modality for distal lower limb defects. This advantage is very valuable in cases of restricted healthcare resources, wars, and during pandemics. In terms of distal limb vascularity, PPFs have no significant impact and can be used safely.

Microscope-Induced Thermal Burns During Lymphaticovenular Anastomosis.

Bright illumination sources using xenon lamps have improved microsurgical visualization under an operating microscope; however, surgeons must recognize the potential for accidental thermal damage to soft tissues.In this article, we present 2 reports of microscopic thermal burn in lymphaticovenular anastomosis (LVA).A 23-year-old woman and a 57-year-old woman with bilateral lymphedema of the legs had LVAs on both legs under local anesthesia. The burn wound in a 23-year-old woman was full thickness, and the one in a 57-year-old woman was deep dermal burn. Both of them healed without skin grafting.Working distance and high illumination intensity are important risk factor. The use of epinephrine as part the local anesthetic mixture that decreases blood flow is also a major risk factor for thermal burns. Lymphaticovenular anastomosis particularly requires high magnification, which leads to increasing the intensity and decreasing the working distance. The surgical conditions around LVA are inherently prone to microscope-induced thermal burns.

Line production system for multiple lymphaticovenular anastomoses.

BACKGROUND: A drawback of multiple lymphaticovenular anastomoses (LVAs) is the need for at least two microsurgeons and the same number of microscopes. In practice, many hospitals find it difficult to access such resources. We have developed a novel line production system (LPS) to address this problem. We assessed whether or not the LPS is better than the conventional dual microscope (DM) system when performing multiple LVAs. METHODS: An LPS group, wherein a novice microsurgeon used loupes to dissect lymphatics and an expert microsurgeon used a microscope to perform the LVAs, and a DM (control) group, wherein the surgeons used microscopes to perform the LVAs. We recorded the lymphatic detection rate through the loupes and the diameter of the detected lymphatics. We also investigated the impact of using the LPS by comparing the number and quality of LVAs and improvement in lymphedema between the study groups. RESULTS: The mean lymphatic detection rate was 81%±15.60%, and the mean size of lymphatics was 0.44 ± 0.12 mm in the LPS. The number of LVAs/h in LPS was significantly higher than that in DM (2.15 ± 0.20 vs. 1.38 ± 0.17; p < 0.01). The number of successful LVAs/h in LPS was significantly higher than that in the DM (2.08 ± 0.22 vs. 0.84 ± 0.14; P < 0.01). Mean rate of improvement in LEL index was significantly higher than that in DM (9.36 ± 1.85 vs. 6.93 ± 1.73; P < 0.01). DISCUSSION: The number and quality of the LVAs increase using the LPS, which leads to further improvement in lymphedema, with fewer microscopes and microsurgeons and a shorter operating time.