Identifying Functional Lymph Nodes in Lower Extremity Lymphedema Patients: The Role of High-frequency Ultrasound.

BACKGROUND: Lymph nodes may play a potential role in lymphedema surgery. Radiologic evaluation of nodes may reveal the status of pathologic conditions but with limited accuracy. This study is the first to evaluate the efficacy of ultrasound in detecting functioning nodes in lymphedema patients and presents a criterion for determining the functionality of the lymph nodes. METHODS: This retrospective study reviews 30 lower extremity lymphedema cases which were candidates for lymph node to vein anastomosis. Lymphoscintigraphy and magnetic resonant lymphangiography (MRL) imaging were compared with ultrasound features which were correlated to intraoperative indocyanine green (ICG) nodal uptake as an indication of functionality. RESULTS: Majority were International Society of Lymphology stage 2 late (50.0%) and stage 3 (26.7%). ICG positive uptake (functioning nodes) was noted in 22 (73.3%), while 8 patients (26.6%) had negative uptake (nonfunctioning). Ultrasound had significantly the highest specificity (100%) for identifying functional nodes followed by lymphoscintigraphy (55%) and MRL (36%; p = 0.002, p < 0.001, respectively). This was associated with 100% positive predictive value compared against lymphoscintigraphy (44%) and MRL (36%; p < 0.001 for both). The identified ultrasound imaging criteria for functioning lymph node were oval lymph node shape (Solbiati Index), morphology, vascularity pattern, and vascularity quantification. CONCLUSION: The use of ultrasound in nodal evaluation was proven effective in different pathologic conditions and demonstrated the best prediction for functionality of the lymph node based on the new evaluation criteria.

Application of a Microsuction Background Device for Microanastomosis in a Rat Femoral Vessel Model.

SUMMARY: Microvascular anastomoses can be challenging to perform when edematous fluids and blood continuously flood and compromise the field of view. Intermittent irrigation and suctioning disturb workflow, require an assistant, and can increase risk of arterial thrombosis from vessels being drawn into suction drains. The authors developed and patented a novel three-dimensionally printed background device with microfluidic capabilities to provide autonomous, continuous irrigation and suction to optimize operator autonomy and efficiency. The authors tested this in a rat femoral vessel model. Twelve end-to-end anastomoses were performed by two senior microsurgeons [six conventional, six suction-assisted background (SAB)] in a rat femoral artery model. The primary outcome was time taken to complete the anastomosis. Secondary outcomes included the validated Structured Assessment of Microsurgery Skills (SAMS) score and the total number of "wiping" events to obtain field clarity. Each procedure was recorded, and videos were independently rated by two blinded experts using the SAMS score. Time taken to complete the anastomosis was greater in the conventional group compared with the SAB group (741.7 ± 203.1 seconds versus 584 ± 155.9 seconds; P = 0.007). The median SAMS score was lower in the conventional group compared with the SAB group (32.3 ± 1.4 versus 38.3 ± 1.5; P = 0.001). The median number of wiping events was significantly greater in the conventional group compared with the SAB group (13 ± 2.2 versus 1.7 ± 1.2; P < 0.001). The authors show that a novel microfluidic background device allows continuous irrigation and suctioning without the need for an assistant, optimizing the efficiency of the microvascular anastomosis. CLINICAL RELEVANCE STATEMENT: The authors have designed a novel, patented, three-dimensionally printed microsurgical background device that provides continuous irrigation and suction, reduces operative time, and provides better vessel clarity during a microsurgical anastomosis compared to standard background.

Hybrid Bionic Nerve Interface for Application in Bionic Limbs.

Intuitive and perceptual neuroprosthetic systems require a high degree of neural control and a variety of sensory feedback, but reliable neural interfaces for long-term use that maintain their functionality are limited. Here, a novel hybrid bionic interface is presented, fabricated by integrating a biological interface (regenerative peripheral nerve interface (RPNI)) and a peripheral neural interface to enhance the neural interface performance between a nerve and bionic limbs. This interface utilizes a shape memory polymer buckle that can be easily implanted on a severed nerve and make contact with both the nerve and the muscle graft after RPNI formation. It is demonstrated that this interface can simultaneously record different signal information via the RPNI and the nerve, as well as stimulate them separately, inducing different responses. Furthermore, it is shown that this interface can record naturally evoked signals from a walking rabbit and use them to control a robotic leg. The long-term functionality and biocompatibility of this interface in rabbits are evaluated for up to 29 weeks, confirming its promising potential for enhancing prosthetic control.

The Role of Escin as a Topical Agent for Lymphedema Treatment in a Rat Model.

Escin, a naturally derived material isolated from horse chestnut, is used as an anti-inflammatory and anti-edema agent. This study aimed to evaluate its effects on lymphedema in a rat tail model. We divided the rats into five groups. The treatment groups received topical application of escin gel at concentrations of 20%, 10%, 2%, and 0.5% for 4 weeks. The fifth group served as a control. We performed volumetric (water displacement) tests, H&E staining, and LYVE-1 immunohistochemical staining, followed by statistical evaluation. All treatment groups showed significant volumetric reductions compared with the control group, but no significant differences were observed between the treatment groups. H&E staining showed a significant reduction in dermal thickness in the 20%, 10%, and 2% escin treatment groups compared to the control group. Within the treatment groups, the 2% escin group showed a significant difference compared with the 20% and 10% escin groups (p = 0.021 for both). LYVE-1 immunohistochemical staining revealed a significantly higher mean lymphatic vessel count in the 2% escin group compared with the 20%, 10%, and 0.5% escin-treated groups and the control group (p = 0.019, p = 0.025, p = 0.019, and p = 0.032 respectively). Topical escin applied to a rat tail model of acute lymphedema resulted in a significant reduction in tail volume, reduced dermal thickness, and increased lymphatic structures. The 2% escin concentration may be the optimal dose for improving lymphedema in this model. Further research is warranted to explore the clinical application of escin in patients with lymphedema.

Decompression of Axillary vein - An essential adjunct for advanced lymphedema.

INTRODUCTION: In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on utilizing the pressure gradient between the high pressure lymphatics and low pressure veins. If the vein pressure in high, the effect affect surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA. MATERIALS AND METHODS: This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimal of at least 12 months); scar-released group (n=25) and control group (n=15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis (BIA)), and major veins (axillary, basilic and cephalic) diameter changes were evaluated. RESULTS: Both groups showed significant reduction in volume and BIA parameters after LVA. The scar-released groups (24/25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared to the control group at 1, 6 and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephailic vein dimeter reduction and BIA measurement. CONCLUSION: The release of perivascular scar in the axially vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephailic vein dimeter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA.

Management of Mid-Vault Asymmetry in Secondary Unilateral Cleft Lip-Nose Deformity.

The focus of secondary rhinoplasty for patients with a cleft lip after facial growth has been on correcting nasal tip asymmetry and distorted cleft-side lower lateral cartilage. However, some patients present with mid-vault asymmetry even after secondary rhinoplasty. The authors propose camouflage procedures for patients with a unilateral cleft lip and without symptoms of nasal airway obstruction. In camouflage procedures, autologous cartilage or acellular dermal matrix was used for onlay grafting and placed on the upper lateral cartilage. In this report, case examples are described to illustrate the surgical techniques and results. This method enables the correction of mid-vault asymmetry without the use of an additional septal spreader graft.

Microsurgical options after the failure of left colon interposition graft in esophagogastric reconstruction.

Colon interposition is commonly used for esophageal reconstruction in patients with a previous gastrectomy. However, when colon interposition fails and alternative reconstruction is required, there are few options for reconstructing the long segment from the esophagus to the stomach. Here, we report on cases of esophagogastric reconstruction with limited alternative options after the failure of transverse and left colon interposition. In these cases, reconstruction was performed using two different microvascular methods: double-pedicle jejunal free flap and supercharged ileocolic interposition graft.

Direction of Flap Rotation in Propeller Flaps: Does It Really Matter?

BACKGROUND: This article investigates the effect of 180° rotating propeller flaps and evaluates whether each flap has a "preferable" rotating direction. METHODS: Part 1 evaluates the flap pedicle velocity and flow volume in neutral, 180°counterclockwise, and clockwise rotated position for 29 consecutive flaps. The data (velocity and volume) were divided into three groups: neutral, high value, and low value group then evaluated. Part 2 compares the outcome from the prospective study where a preferable rotation with high value was selected against 29 patients from 2012 to 2016 who had the same operation without selecting a preferable rotation direction. RESULTS: In part 1, the three groups (neutral, high value, and low value groups) showed mean velocity of 28.06 ± 7.94, 31.92 ± 10.22, 24.41 ± 8.12 cm/s, respectively, and mean volume of 6.11 ± 4.95, 6.83 ± 6.69, 4.62 ± 3.55 mL/min, respectively. The mean velocity and volume of the perforator in the high value group were significantly higher than that in the low value group (p = 0.0001). In part 2, although no statistical significance in the outcome was observed, there were two cases of total, two cases of partial flap loss, and three cases of wound dehiscence in the patients where preferable rotations was not selected compared with only two wound dehiscence for flaps with preferable rotation. CONCLUSION: The velocity and flow of the flap are significantly different based on the rotation direction of the flap. Using the preferred rotation direction with statistically higher value of velocity and flow may increase the overall outcome of the propeller flap, especially where larger flaps are used.

Is Early Compression Therapy after Perforator Flap Safe and Reliable?

BACKGROUND: Due to the concern of circulation compromise, many surgeons hesitate to dangle or challenge the flap in the early postoperative phase. In our experience, early compression may have advantages such as collapse of dead space, evacuation of hematoma, reduction of edema, and stabilization of flap when ambulating. In this study, the effect of early compression of flaps with regard to flap physiology and outcome is evaluated. METHODS: From postoperative day 3 to 5, a custom-made compression garment was fitted aiming to compress with a pressure of 30 to 35 mmHg. A total of 52 patients (52 flaps) were enrolled for the study and 48 flaps underwent early compression. The compression was applied not only over the flap but also over the extremity or trunk. The flap outcome as well as flow velocity and flow volume of the pedicle before and after compression was measured and evaluated. RESULTS: There was no flap complication during the early compression and early ambulation. And, there was no statistical difference either in the flow velocity or in the volume before and after the compression therapy (29.21 vs. 29.42 cm/s and 7.13 vs. 6.56 cm3/s, respectively). CONCLUSION: Early compression with a 30-mmHg pressure customized pressure garment after the flap surgery does not affect the hemodynamics of the perforator and can be safely used after extremity reconstruction before ambulation.

Use of a helical composite free flap for alar defect reconstruction with a supermicrosurgical technique.

The highly contoured nature of the nose and the abundant free margin makes it especially difficult to reconstruct. In this report, we describe the use of a new helical rim free flap technique for the reconstruction of full-thickness nasal alar defects via supermicrosurgery. Briefly, after a wide excision with a margin of 0.7 cm, an alar defect with a size of 1×1×0.5cm was obtained, which included the full thickness of the skin, mucosa, and lower lateral cartilage. Vessel dissection was performed in a straightforward manner, starting from the incision margin for flap harvest, without any further dissection for reach the greater trunk of the superficial temporal artery. The flap was inset in order to match the contour of the contralateral ala. We closed the donor site via rotation and advancement. No donor site morbidity was observed, despite the presence of a small scar that could easily be covered with hair. The alar contour was satisfactory, and the patient was satisfied with the results. The supermicrosurgical technique did not require further dissection to identify the vessels for anastomosis, leading to better cosmetic outcomes and a reduced operating time.

Reconstruction of Temporal Bone Defect Using a Vertically-Oriented Free Muscle-Sparing Rectus Abdominis Musculocutaneous Flap.

Reconstruction of a temporal bone defect after tumor ablation should provide watertight filling and adequate resurfacing. A muscle-sparing rectus abdominis musculocutaneous (ms-RAMC) flap with de-epithelized skin paddle has been used and early experience was reported. Case series enrolled 7 patients who underwent free ms-RAMC flap after tumor ablation for external auditory canal cancer. Vertically oriented flap was harvested with central strip of muscle. Distal skin paddle was de-epithelized to fill the bony defect. Immediate facial nerve reconstruction was performed whenever indicated. The average operation time for reconstruction was 280 minutes. No early complication was reported. An ms-RAMC flap with de-epithelized skin paddle can be used for temporal bone defect reconstruction with its anatomic consistency and technical simplicity. It can provide sufficient bulk for water tight packing that lasts after irradiation. The 11th intercostal nerve can be harvested during pedicle dissection. Muscle sparing technique could minimize donor-site morbidity.

Thin elevation: A technique for achieving thin perforator flaps.

Elevating thin flaps has long been a goal of reconstructive surgeons. Thin flaps have numerous advantages in reconstruction. In this study, we present a surgical method for elevating a thin flap and demonstrate the safety of the procedure. A retrospective review was performed of the electronic medical records of patients who underwent thin flap elevation for lower extremity reconstruction from April 2016 to September 2016 at the Department of Plastic Surgery of Asan Medical Center. All flaps included in this study were elevated above the superficial fascia. A total of 15 superficial circumflex iliac artery free flaps and 13 anterolateral thigh free flaps were enrolled in the study. The total complication rate was 17.56% (n=5), with total loss of the flap in one patient (3.57%) and partial necrosis of the flap in four patients (14.28%). No wound dehiscence or graft loss at the donor wound took place. Elevation above the superficial fascia is not inferior in terms of flap necrosis risk and is superior for reducing donor site morbidity. In addition to its safety, it yields good aesthetic results.

Weight analysis of mastectomy specimens and abdominal flaps used for breast reconstruction in Koreans.

BACKGROUND: Slim patients or those with large breasts may be ineligible for breast reconstruction with an abdominal flap, as the volume of the flap may be insufficient. This study aimed to establish that abdominal tissue-based breast reconstruction can be well suited for Korean patients, despite their thin body habitus. METHODS: A total of 252 patients who underwent postmastectomy breast reconstruction with an abdominal flap from October 2006 to May 2013 were retrospectively reviewed. The patients' age and body mass index were analyzed, and a correlation analysis was performed between the weight of the mastectomy specimen and that of the initial abdominal flap. RESULTS: The average weights of the mastectomy specimen and initial abdominal flap were 451.03 g and 644.95 g, respectively. The ratio of the weight of the mastectomy specimen to that of the initial flap was 0.71±0.23. There was a strong positive linear relationship between the weight of the mastectomy specimen and that of the initial flap (Pearson correlation coefficient, 0.728). Thirty nulliparous patients had a final-to-initial flap weight ratio of 0.66±0.11. The 25 patients who underwent a contralateral procedure had a ratio of 0.96±0.30. The adjusted ratio of the final flap weight to the initial flap weight was 0.66±0.12. CONCLUSIONS: Breast weight had a strong positive relationship with abdominal flap weight in Koreans. Abdominal flaps provided sufficient soft tissue for breast reconstruction in most Korean patients, including nulliparous patients. However, when the mastectomy weight is estimated to be >700 g, a contralateral reduction procedure may be considered.

3D computer simulation analysis of the flap volume change in total tongue reconstruction flaps.

BACKGROUND: A decreased flap volume can be an obstacle to proper phonation and swallowing. In this study we verified the proportion of volume decrease using 3D reconstructed images and identified the contributors to flap volume loss. METHODS: We retrospectively analyzed all patients who underwent radical excision of tongue cancer and reconstructive surgery in our institution from January 2003 to October 2016. Segmentation of the DICOM images, 3D rendering of the neotongue flap, and analysis of the reconstructed images were performed using SPlanner V1® software. RESULTS: The first postoperative imaging work-up was performed within an average of 22 days (T1). The last follow-up images were taken at an average of 6.25 months (T2). The mean flap volume at T2 was reduced to 82.99 per cent compared with T1, and flap height was reduced to 91.85 per cent, giving mean volume and height decreases of 17.01 per cent and 8.15 per cent, respectively. Neither the volume/height difference between T1 and T2 nor the flap volume/height discrepancy compared with the preoperative tongue affected speech or feeding function. The difference between the flap and preoperative tongue volumes was significantly related to the presence of complications (p = 0.0153). Initial flap volume was significantly related to the flap volume reduction (p = 0.0159). CONCLUSIONS: The mean flap volume reduction is the only factor significantly related to initial flap volume. Our realistic 3D reconstructed image and novel software enables us to more precisely predict the flap volume of the postoperative state and preoperatively evaluate the required flap size for covering defects.

Cleft-Related Orthognathic Surgery Based on Maxillary Vertical Lengthening of the Anterior Facial Height.

BACKGROUND: The conventional approach during orthognathic surgery for cleft-related deformities has focused largely on restoration of maxilla retrusion, using the maxillary advancement as a standard treatment objective. However, the authors thought that maxillary vertical shortening and deficient incisor show could be additional key elements of cleft-related deformities. Although slight vertical lengthening can be obtained with only maxillary advancement, it would not be enough to obtain satisfactory aesthetic results in terms of the anterior facial height. The authors hypothesized that vertical deficiency and anteroposterior maxillary retrusion exists in cleft-related deformities. Therefore, orthognathic surgery including intentional vertical lengthening and advancement would be better than the conventional simple advancement. METHODS: A new approach was used to treat consecutive patients with dentofacial deformities between December of 2007 and December of 2016. Patients with cleft-related dentofacial deformities were included in the study. RESULTS: Forty-one patients with cleft-related dentofacial deformities were included. The distance from the nasion to the incisor tip was 76.70 mm; the angle of the lines connecting the sella, nasion, and point A was 74.03 degrees; and the incisor show was 1.02 mm. Corresponding measurements in 40 patients without clefts were 81.57 mm, 80.08 degrees, and 3.38 mm, respectively. Postoperatively, the average vertical lengthening achieved was 0.88 mm in the simple maxillary advancement group and 7.65 mm in the intentional vertical lengthening accompanied by maxillary advancement group. CONCLUSION: The authors' results suggest that simultaneous maxillary vertical lengthening with horizontal advancement is a viable approach to orthognathic surgery for cleft-related deformities, given the long-term stability of outcomes demonstrated in this study. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Study of the Medial Superficial Perforator of the Superficial Circumflex Iliac Artery Perforator Flap Using Computed Tomographic Angiography and Surgical Anatomy in 142 Patients.

BACKGROUND: The two major perforators supplying the superficial circumflex iliac artery perforator flap are the medial (superficial) and lateral (deep) perforators; however, they lack detailed description. The purpose of this study was to clarify the anatomy. METHODS: In a prospective analysis of 142 patients, computed tomographic angiograms of 284 superficial circumflex iliac artery perforator regions were evaluated, and 142 superficial circumflex iliac artery perforator flaps were surgically correlated. The origin of the superficial circumflex iliac artery, the origin of the medial perforator, the location where it penetrates the deep fascia, and its pattern of pathway after penetration of the superficial fascia were evaluated. RESULTS: There was 100 percent correlation between computed tomographic angiogram and surgical findings. The superficial circumflex iliac artery originates mostly from the femoral artery in 84.8 percent. The medial perforator originated from the superficial circumflex iliac artery in 94 percent. The medial perforator typically penetrated the deep fascia within an oval of 4.2 × 2 cm located 4.5 cm lateral and 1.5 cm superior from the pelvic tubercle. After passing the superficial fascia, the medial perforator either anchored directly into skin (56 percent) or traveled in an axial pattern (44 percent) beyond the anterior superior iliac spine. CONCLUSIONS: Despite the origin of the medial perforator, it was constantly observed penetrating the deep fascia. However, the pathway of the medial perforator can be either anchoring directly into the dermis or extending as an axial pattern artery, implicating a different effect on the survival of the flap. These new findings will allow better understanding for elevating the superficial circumflex iliac artery perforator flap based on the medial perforator.