Retroauricular lymph node flap: An anatomic and surgical feasibility study.

BACKGROUND: The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS: Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS: The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS: The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.

Surgical Anatomy of Temporalis Muscle Transfer with Fascia Lata Augmentation for the Reanimation of the Paralyzed Face: A Cadaveric Study.

Background The temporalis muscle flap transfer with fascia lata augmentation (FLA) is a promising method for smile reconstruction after facial palsy. International literature lacks a detailed anatomical analysis of the temporalis muscle (TPM) combined with fascia lata (FL) augmentation. This study aims to describe the muscle's properties and calculate the length of FL needed to perform the temporalis muscle flap transfer with FLA. Methods Twenty nonembalmed male (m) and female (f) hemifacial cadavers were dissected to investigate the temporalis muscle's anatomy. Results The calculated minimum length of FL needed is 7.03cm (f) and 5.99cm (m). The length of the harvested tendon is 3.16cm/± 1.32cm (f) and 3.18/± 0.73cm (m). The length of the anterior part of the temporalis muscle (aTPM) is 4.16/± 0.80cm (f) and 5.30/± 0.85cm (m). The length of the posterior part (pTPM) is 5.24/± 1.51cm (f) and 6.62/± 1.03cm (m). The length from the most anterior to the most posterior point (aTPMpTPM) is 8.60/± 0.98cm (f) and 10.18/± 0.79cm (m). The length from the most cranial point to the distal tendon (cTPMdT) is 7.90/± 0.43cm (f) and 9.79/± 1.11cm (m). Conclusions This study gives basic information about the temporalis muscle and its anatomy to support existing and future surgical procedures in their performance. The recommended minimum length of FL to perform a temporalis muscle transfer with FLA is 7.03cm for female and 5.99cm for male, and minimum width of 3 cm. We recommend harvesting some extra centimeters to allow adjusting afterward.

Using the serratus anterior free flap for dynamic facial reanimation: Systematic review.

It was the purpose of this study to evaluate the role of the serratus anterior free flap (SAFF) with its long thoracic nerve (LTN) as composite flap for dynamic facial reanimation. A total of 10 studies, published between 2004 and 2021, met inclusion criteria. Clinical data of 48 patients were used for the systematic review and analysis. One to three slips were used, mainly as one-stage procedures (n = 39; 81.3%), to create different force vectors. Single or double innervated muscle transfers were utilized in 32 (66.7%) and 16 (33.3%) cases with additionally harvested skin paddles in 4 (8.3%) patients. The LTN was mostly anastomosed to the ipsilateral masseteric nerve (45.8%; n = 22) or to remaining facial nerve branches (37.5%; n = 18), while cross-facial-nerve-grafting was rarely used (16.7%; n = 8). The SAFF as composite flap with different force vectors proved to be a good candidate for immediate dynamic facial reanimation after any midface defects.

Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review.

BACKGROUND: Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS: Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS: One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION: Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Exclusive use of ultrasound for locating optimal LVA sites-A descriptive data analysis.

BACKGROUND: The current standard to locate lymphatic vessels for lymphovenous anastomosis (LVA) is the use of indocyanine green (ICG)-lymphangiography. Due to fluid retention and fibrosis of tissue in patients with lymphedema, often present in Caucasian patients, vessels deeper than 0.5 cm below the dermis cannot be visualized. We present our experiences with ultrasound in locating deeper lymphatic vessels in lower extremities. MATERIALS AND METHODS: In total, 28 patients with lymphedema and positive lymphoscintigraphy were included. With ultrasound, we located 82 lymphatic vessels in lower extremities preoperatively without the use of ICG marking. Vessel diameter, depth, and exact location were examined. Using a coordinate system, a mapping of the detected lymphatic vessels was created. The ultrasound findings were confirmed under microscope and ICG intraoperatively. RESULTS: In all, we detected 28 Caucasian patients and 82 lymphatic vessels with ultrasound preoperatively. On average, we found three lymphatic vessels (range, 2-6) at each patient. Of the ultrasound-detected lymphatic vessels, 90.2% could be verified intraoperatively under a microscope. Before skin incision, lymphatic vessels could be visualized in 40% of our patients with ICG. In the mapping of the lymphatic vessels, we found no significant pattern. CONCLUSION: Ultrasound can precisely detect lymphatic vessels for efficient LVA operation without the prior use of ICG-lymphangiography.

The correlation of the perforators and the accessory saphenous vein in a profunda femoris artery perforator flap for additional venous anastomosis: A cadaveric study and clinical application.

BACKGROUND: The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. To establish a safer flap elevation technique, we focused on the topology of the accessory saphenous vein in the medial thigh area. We hypothesize that including the accessory saphenous vein in a PAP flap results in safer PAP flap transfer with two venous drainage systems. The aim of this study was to describe the anatomical relationship between the perforators and the accessory saphenous vein in the PAP flap using fresh cadavers and to describe the relationship through two clinical cases. METHODS: For the anatomical study, 19 posterior medial thigh regions from 10 fresh cadavers were dissected. We recorded the number, site of origin, the length, and the diameter of the pedicle. We also documented the course, the length, and the diameter of the accessory saphenous vein. PAP flap transfer with additional accessory saphenous vein anastomosis was performed in two clinical cases; a 40-year-old female with tongue cancer and a 51-year-old female with breast cancer. RESULTS: In all cadaveric specimens, the accessory saphenous vein was found above the deep fascia. The average distance between the proximal thigh crease and the intersection of the anterior edge of the gracilis muscle and the accessory saphenous vein was 7.7 ± 2.5 cm. The diameter of the accessory saphenous vein averaged 3.1 ± 1.1 mm. The average accessory saphenous vein length from its takeoff from the great saphenous vein to the anterior edge of the gracilis muscle was 4.2 ± 1.3 cm. In clinical cases, the flap size was 6 x 18 cm and 8 x 21 cm and the follow-up length was 12 and 3 months, respectively. In both cases, the postoperative course was uneventful and the flap survived completely. CONCLUSION: Anatomical study confirmed that the accessory saphenous vein did exist in all specimens and it could be included in the PAP flap with sufficient length and relatively large diameter. Although further clinical investigation will be required to confirm its efficacy, a PAP flap including the accessory saphenous vein may decrease the chances of flap congestion.