Posterior auricular artery free flap reconstruction of the retroauricular sulcus in microtia repair.

BACKGROUND: Autologous repair using costal cartilage grafts remains the most widely accepted method of microtia reconstruction. A major complication of current techniques is loss of ear shape caused by scarring, contracture and cartilage absorption. We present a new surgical technique utilizing the posterior auricular artery free flap in microsurgical reconstruction of the retroauricular sulcus in microtia. METHOD: Reconstruction is performed in two stages. In the first stage, a fabricated costal cartilage framework is inserted into a skin pocket as described by Nagata. In the second stage, the ear framework is elevated from the scalp and held by an additional cartilage wedge. Following indocyanine green angiography perforator mapping, a posterior auricular artery perforator flap is harvested from the contralateral (normal) ear and used to reconstruct the posterior auricular sulcus covering the cartilage framework and elevating wedge. RESULTS: The technique was applied to three patients aged 11-15 years with a follow-up time of 8 months to 3 years. The average flap artery diameter was 0.73 mm and the vein was 0.7 mm. Venous congestion occurred in one case and was resolved with a vein graft leading to complete flap recovery. Good ear shape, elevation, projection, skin color and texture were achieved in all the cases. CONCLUSION: Posterior auricular artery flap reconstruction of the retroauricular sulcus in microtia repair is a useful alternative to the current skin graft and tissue expander-based techniques. It provides the ideal skin color and texture match and may improve the overall results of microtia reconstruction by enhancing vascularity.

Local Flaps with Negative Pressure Wound Therapy in Secondary Reconstruction of Myelomeningocele Wound Necrosis.

Major wound necrosis is an uncommon yet critical complication of meningomyelocele surgical repair with few reports available. Management is demanding and often requires further reconstructive surgery. We report a case of a neonate who developed extensive wound necrosis with dehiscence following primary repair of myelomeningocele. The large defect was reconstructed using transposition fasciocutaneous flaps and negative pressure wound therapy applied over the flap donor sites resulting in wound closure, alleviating the need for further surgery. We report this case to highlight the importance of local flap design in reconstruction of the complex wounds seen following meningomyelocele repair wound necrosis. Additionally, we report the unique utilization of negative pressure wound therapy in the management of myelomeningocele.

Establishment of supermicrosurgical lymphaticovenular anastomosis model in rat.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is becoming a choice of treatment for compression-refractory lymphedema. However, LVA requires highly sophisticated microsurgical technique called supermicrosurgery, and no training model for LVA has been developed. This study aimed to develop and evaluate feasibility of a new LVA model using rat thigh lymphatic vessels. METHODS: Ten Sprague-Dawley rats were used for the study. After preoperative indocyanine green (ICG) lymphography, lymphatic vessels in posteromedial aspect of the thigh were dissected. In right limbs, the largest lymphatic vessel was anastomosed to the short saphenous vein or its branch, and the remaining lymphatic vessels were ligated (LVA group). In left limbs, all lymphatic vessels were ligated (control group). Anastomosis patency was evaluated intraoperatively and at postoperative 7 days. RESULTS: Courses of lymphatic vessels in the thigh were constant; lymphatic vessels run along the short saphenous vein. The mean diameter of lymphatic vessel used for LVA was 0.240 ± 0.057 mm, and the mean diameter of vein was 0.370 ± 0.146 mm. All lymphatic vessels were translucent and very thin like human intact lymphatic vessels. In LVA group, intra- and post-operative anastomosis patency rates were 100% (10/10) based on ICG lymphography. In control group, intra- and post-operative patency rates were 0% (0/10). CONCLUSIONS: Rat lymphatic vessels are thin, translucent, and fragile similar to intact human lymphatic vessels. The LVA model uses easily accessible lymphatic vessels in the thigh, and is useful for training of supermicrosurgical LVA. © 2014 Wiley Periodicals, Inc. Microsurgery 37:57-60, 2017.

Genital Lymphedema Score: Genital Lymphedema Severity Scoring System Based on Subjective Symptoms.

BACKGROUND: Genital lymphedema (GL) causes irritating symptoms such as urinary troubles due to genital edema and genital lymphorrhea, which deteriorate patients' quality of life. Indocyanine green genital lymphography has been reported to be useful for severity evaluation of GL but is not available in all medical settings. More convenient and simple severity evaluation methods are required in clinical practice. METHODS: Thirty-two female secondary lower extremity lymphedema patients with GL were evaluated using the genital lymphedema score (GLS) based on patients' symptoms related to GL (score from 0 to 9; higher is worse) and the genital dermal backflow (GDB) stage based on indocyanine green lymphography findings. The GLS was compared according to GDB stage. RESULTS: The GLS ranged from 1 to 9 (mean, 3.0), and GDB stage ranged from I to IV (9 in GDB stage I, 13 in GDB stage II, 8 in GDB stage III, and 2 in GDB stage IV). There was a significant difference between GLS in GDB stage I, GDB stage II, GDB stage III, and GDB stage IV [1.2 (0.4), 2.4 (0.5), 4.8 (0.9), and 8.0 (1.4), respectively; P < 0.001). CONCLUSIONS: The GLS was well associated with pathophysiological GL severity staging system and increased with progression of GDB stage. Because GLS is more convenient and simple than GDB stage, GLS is useful for primary evaluation of GL.

Efferent Lymphatic Vessel Anastomosis: Supermicrosurgical Efferent Lymphatic Vessel-to-Venous Anastomosis for the Prophylactic Treatment of Subclinical Lymphedema.

BACKGROUND: In lower extremity lymphedema secondary to pelvic cancer treatments, lymphedema develops despite that the inguinal lymph nodes (LNs) are preserved. Obstruction of the efferent lymphatic vessels of the inguinal LNs causes lower extremity lymphedema, and it is considered a radical treatment to bypass the efferent lymphatic vessel. METHODS: Efferent lymphatic vessel anastomosis, supermicrosurgical efferent lymphatic vessel-to-venous anastomosis, was performed on 14 legs with subclinical lymphedema [leg dermal backflow (LDB) stage I]. Efferent lymphatic vessel anastomosis was performed under local anesthesia at the groin region, and an efferent lymphatic vessel of the inguinal LN is anastomosed to a recipient vein. Feasibility and postoperative results were evaluated. RESULTS: All 14 efferent lymphatic vessel anastomoses were successfully performed without perioperative complication. All legs could be free from lymphedematous symptoms without perioperative compression at postoperative 1 year. Postoperative LDB stage included LDB stage 0 (n = 8) and LDB stage I (n = 6), which was significantly downstaged compared with preoperative LDB stage (P < 0.001). CONCLUSIONS: Efferent lymphatic vessel anastomosis allowed lymph flow bypass after filtration by the superficial inguinal LN through a skin incision along the inguinal crease, and was effective to prevent development of symptomatic lymphedema in subclinical lymphedema cases.

Relationship Between Lymphedema and Arteriosclerosis: Higher Cardio-Ankle Vascular Index (CAVI) in Lymphedematous Limbs.

BACKGROUND: Arteriosclerosis is one of the most important public health issues because it is very common in developed countries and its sequelae are lethal. Lymphatic vessel insufficiency has been reported to be associated with atherogenesis. Lymphedema seems to affect progression of arteriosclerosis, but no clinical study has been reported. METHODS: Forty-eight limbs of 24 female patients with pelvic cancer-related lower extremity lymphedema (LEL) were evaluated. Cardio-ankle vascular index (CAVI), an indirect estimate of the arterial stiffness, was measured in each limb. Cardio-ankle vascular index was compared according to known arteriosclerosis risk factors including age (younger than 65 years vs 65 years), body mass index (BMI; <25 vs 25 kg/m), hypertension (HT), diabetes mellitus, hyperlipidemia (HL), and smoking, as well as according to LEL-related factors including duration of LEL (<5 years vs 5 years), pelvic irradiation, leg cellulitis, LEL index (<250 vs 250), and leg dermal backflow (LDB) stage (LDB stage 0/I vs LDB stage II/III/IV/V) using univariable analyses and multivariable analysis. RESULTS: Univariable analyses revealed statistically significant differences in CAVI between lower BMI and higher BMI [7.19 (0.75) vs 8.36 (1.24), P < 0.01], HT (-) and HT (+) [7.25 (0.81) vs 8.17 (1.29), P < 0.01], HL (-) and HL (+) [7.19 (0.74) vs 8.06 (1.27), P < 0.01], and lower LDB stage and higher LDB stage [6.87 (0.65) vs 7.76 (1.05), P < 0.01]. Multivariable analysis revealed statistically significant differences in CAVI between lower BMI and higher BMI (P < 0.01), shorter duration of LEL and longer duration of LEL [7.21 (1.04) vs 7.71 (0.97), P = 0.04], and lower LDB stage and higher LDB stage (P = 0.04) CONCLUSIONS: Higher BMI, longer duration of LEL, and higher LDB stage were independent factors associated with higher CAVI in pelvic cancer-related LEL.

Ultrasound visualization of the lymphatic vessels in the lower leg.

BACKGROUND: Identification of lymphatic vessels for lymphaticovenular anastomosis (LVA), which is an effective surgical treatment for obstructive lymphedema, is important. Indocyanine green (ICG) lymphography is useful for that purpose, but is not common in many institutions. Although ultrasound is a very common modality, no research has yet underlined the feasibility of the device to detect the lymphatic vessels. METHODS: First, identification of lymphatic vessels in the lower legs using ultrasound was performed in non-edematous limbs with linear-pattern on ICG lymphography (n = 12). The imaging findings and characteristic of the lymphatic vessels in ultrasonography were investigated on transverse scans. Second, to assess the ultrasound detection technique, ICG was injected to healthy volunteers after identification and marking of the lymphatic vessels using ultrasound (n = 14). Sensitivity and specificity of the examination were calculated. RESULTS: In the first part, the lymphatic vessels were detected by ultrasound in all cases. Characteristic ultrasonography findings of lymphatic vessels included homogeneous, hypoechoic and spicular misshapen images in all cases. In the second part, the overall sensitivity and specificity were 95.5 and 92.9%, respectively. CONCLUSIONS: Ultrasonography can identify lymphatic vessels of the lower leg with precision and may aid lymphatic microsurgery for lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:397-401, 2016.

Preoperative color Doppler ultrasound assessment of the lateral thoracic artery perforator flap and its branching pattern.

The anatomy of the lateral thoracic artery perforator flap remains controversial, but this region is extremely useful as a reconstructive donor site. In this report, we describe the usefulness of the preoperative color Doppler ultrasound evaluation for the harvesting of the lateral thoracic artery perforator flap, and we clarify its branching pattern. Twenty-seven patients underwent the preoperative color Doppler ultrasound assessment before perforator flaps were harvested. We evaluated the branching pattern and the diameter of the flaps by direct observation. All flaps were successfully transferred, and it was found that the branching pattern of the lateral thoracic perforator is divided into three groups: the superficial branch, the medial branch, and the deep branch. Their appearance ratios were 48.1% (13/27), 14.8% (4/27), and 81.5% (22/27), respectively. The lateral thoracic artery perforator flap has a great deal of anatomical variation, and vessels with relatively small diameters compared to those of other flaps. This is why flaps from this region are not currently popular. This study revealed the superiority of the color Doppler ultrasound for preoperative planning of the lateral thoracic artery perforator flap elevation. Furthermore, the branching pattern and the diameters of the different branches were specified.