Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?

This is the first report on the effectiveness of minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema. Fifty-two patients (age: 15 to 78 years old; 8 males, 44 females) were treated with lymphaticovenular anastomoses under local anesthesia and by postoperative compression using elastic stockings. The average duration of edema of these patients before treatment was 5.3 +/- 5.0 years. The average number of anastomosis in each patient was 2.1 +/- 1.2 (1-5). The patients were followed for an average of 14.5 +/- 10.2 months, and the result were considered effective (82.5%) even for the patients with stage III (progressive edema with acute lymphangitis) and IV (fibrolymphedema), but others showed no improvement. Among these cases, 17 patients showed reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference excluding edema in bilateral legs was 41.8 +/- 31.2% of the preoperative excess length. These results indicate that minimal invasive lymphaticovenular anastomosis under a local anesthesia is valuable instead of general anesthesia.

New one-stage nerve pedicle grafting technique using the great auricular nerve for reconstruction of facial nerve defects.

A new one-stage nerve pedicle grafting technique, employing a vascularized great auricular nerve graft, was used to repair a facial nerve defect. The facial nerve of a 39-year-old woman with facial schwannoma was resected, and an island vascularized great auricular nerve graft from the ipsilateral side was transferred to bridge a 4 cm long defect of the buccal branch. Postoperatively, rapid nerve sprouting through the vascularized nerve graft and excellent facial reanimation were obtained within 6 months after surgery. This method in one-stage using a vascularized nerve graft is technically easy, requires a short operating time, has minimal donor-site morbidity, and leads to successful nerve regeneration postoperatively.

Sequential vascularized iliac bone graft and a superficial circumflex iliac artery perforator flap with a single source vessel for established mandibular defects.

The major problems in dealing with established mandibular loss are severe soft-tissue contracture and a limited number of recipient vessels. The skin portion of the iliac osteocutaneous flap often necrotizes in cases without perforators of the deep circumflex iliac vessel. To overcome these problems, eight patients with established mandibular loss and no skin perforators of the deep circumflex iliac vessel were treated with a sequential vascularized iliac bone graft and a superficial circumflex iliac perforator flap with a single recipient vessel. Regarding the recipient vessels, the ipsilateral cervical vessels were used for four patients, and the contralateral facial and ipsilateral superficial temporal vessels were used for two cases each. The superficial circumflex iliac perforator flaps were 7 to 28 cm in length and 3 to 15 cm in width. The iliac bone grafts ranged from 7 to 13 cm in length, and three cases were repaired with the inner cortex of the iliac bone. There were no serious complications, such as flap necrosis or bone infection and resulting absorption. The advantages of this method are that both pedicles are very close to each other and of suitable diameter for anastomosis. Simultaneous flap elevation and preparation for the recipient site is possible. The skin flap and vascularized bone graft can be obtained from the same donor site. A single source vessel can nourish both the large skin area and bone sequentially. Longer dissection of the superficial circumflex iliac system to the proximal femoral division is unnecessary. A large flap can survive with a short segment of the superficial circumflex iliac system. Only the vascularized inner cortex of the iliac bone needs to be used, and the outer iliac cortex can be preserved, which results in less morbidity at the donor site.

Medial and lateral malleolar perforator flaps for repair of defects around the ankle.

Reconstruction for defects around the ankle continues to be challenging. Repairs have been effected with the dorsalis pedis flap, the medial plantar flap, and with reverse-flow island flaps using the anterior and posterior tibial systems and the peroneal system. However, sacrifice of the major vessels of the lower leg and wide and long scars at the donor site are disadvantages of these flaps. To overcome these disadvantages, the authors developed island lateral and medial malleolar flaps with the perforators located close to the ankle. These flaps are easy to elevate, involve a short operating time, require no sacrifice of major vessels or muscles of the lower legs, and the use of these adipofascial flaps makes donor scars more acceptable. Malleolar perforator flaps are suitable for the repair of small ankle defects.

Long-term follow-up after lymphaticovenular anastomosis for lymphedema in the leg.

Over the last 9 years, the authors analyzed lymphedema of the lower extremity in a total of 25 patients, comparing the use of supermicrosurgical lymphaticovenular anastomosis and/or conservative treatment. The most common cause of edema was hysterectomy, with or without subsequent radiation therapy for uterine cancer. Among 12 cases that underwent only conservative treatment, only one case showed a decrease of over 4 cm in the circumference of the lower leg. The average period for conservative treatment was 1.5 years, and the average decreased circumference was 0.6 cm (8 percent of the preoperative excess). Thirteen patients were followed after lymphaticovenular anastomoses, as well as pre- and postoperative conservative treatment. The average follow-up after surgery was 3.3 years, and eight patients showed a reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference, excluding edema in the bilateral leg, was 4.7 cm (55.6 percent of the preoperative excess). These results indicate that supermicrosurgical lymphaticovenular anastomosis has a valuable place in the treatment of lymphedema.

Dynamic reconstruction of large abdominal defects using a free rectus femoris musculocutaneous flap with normal motor function.

Reconstruction of large abdominal wall defects with conventional reconstruction including the component separation technique is difficult because of strong transverse tension and loss or weakness of the rectus abdominis muscle. To overcome this problem, dynamic reconstruction of the abdominal wall using a free innervated rectus femoris musculocutaneous flap was performed for large defects with separation of the bilateral rectus abdominis muscles. The intact motor nerve of the rectus femoris muscle was transferred without transection, and only the pedicle vessels were anastomosed to the omental vessels. Four and one-half years after surgery, the rectus femoris muscle had voluntary strong muscle contraction and there was no abdominal protrusion, herniation, or donor morbidity. This new method with dynamic function can replace conventional techniques for large abdominal defects without rectus muscle function.