Pathological changes of adipose tissue in secondary lymphoedema.

BACKGROUND: The pathophysiology of lymphoedema is poorly understood. Current treatment options include compression therapy, resection, liposuction and lymphatic microsurgery, but determining the optimal treatment approach for each patient remains challenging. OBJECTIVES: We characterized skin and adipose tissue alterations in the setting of secondary lymphoedema. METHODS: Morphological and histopathological evaluations were conducted for 70 specimens collected from 26 female patients with lower-extremity secondary lymphoedema following surgical intervention for gynaecological cancers. Indocyanine green lymphography was performed for each patient to assess lymphoedema severity. RESULTS: Macroscopic and ultrasound findings revealed that lymphoedema adipose tissue had larger lobules of adipose tissue, with these lobules surrounded by thick collagen fibres and interstitial lymphatic fluid. In lymphoedema specimens, adipocytes displayed hypertrophic changes and more collagen fibre deposits when examined using electron microscopy, whole-mount staining and immunohistochemistry. The number of capillary lymphatic channels was also found to be increased in the dermis of lymphoedema limbs. Crown-like structures (dead adipocytes surrounded by M1 macrophages) were less frequently seen in lymphoedema samples. Flow cytometry revealed that, among the cellular components of adipose tissue, adipose-derived stem/stromal cells and M2 macrophages were decreased in number in lymphoedema adipose tissue compared with normal controls. CONCLUSIONS: These findings suggest that long-term lymphatic volume overload can induce chronic tissue inflammation, progressive fibrosis, impaired homeostasis, altered remodelling of adipose tissue, impaired regenerative capacity and immunological dysfunction. Further elucidation of the pathophysiological mechanisms underlying lymphoedema will lead to more reliable therapeutic strategies.

Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphoedema.

OBJECTIVES: Indocyanine green (ICG) lymphography has been reported to be useful for the early diagnosis of lymphoedema. However, no study has reported the usefulness of ICG lymphography for evaluation of lymphoedema with lower extremity dysmorphia (LED). This study aimed to elucidate independent factors associated with LED in secondary lower extremity lymphoedema (LEL) patients. METHODS: This was a retrospective observational study of 268 legs of 134 secondary LEL patients. The medical charts were reviewed to obtain data of clinical demographics and ICG lymphography based severity stage (leg dermal backflow [LDB] stage). LED was defined as a leg with a LEL index of 250 or higher. Logistic regression analysis was used to identify independent factors associated with LED. RESULTS: LED was observed in 106 legs (39.6%). Multivariate analysis revealed that independent factors associated with LED were higher LDB stages compared with LDB stage 0 (LDB stage III; OR 17.586; 95% CI 2.055-150.482; p = .009) (LDB stage IV; OR 76.794; 95% CI 8.132-725.199; p < .001) (LDB stage V; OR 47.423; 95% CI 3.704-607.192; p = .003). On the other hand, inverse associations were observed in higher age (65 years or older; OR 0.409; 95% CI 0.190-0.881; p = .022) and higher body mass index (25 kg/m2 or higher; OR 0.408; 95% CI 0.176-0.946; p = .037). CONCLUSIONS: Independent factors associated with LED were elucidated. ICG lymphography based severity stage showed the strongest association with LED, and was useful for evaluation of progressed LEL with LED.

Phenotypic modulation of smooth muscle cells in lymphoedema.

BACKGROUND: Lymphoedema is a debilitating progressive condition that is frequently observed following cancer surgery and severely restricts quality of life. Although it is known that lymphatic dysfunction and obstruction underlie lymphoedema, the pathogenic mechanism is poorly understood. Smooth muscle cells (SMCs) play pivotal roles in the pathogenesis of various vascular diseases, including atherosclerosis. OBJECTIVES: We analysed SMCs in lymphatic vessels from the lymphoedematous legs of 29 patients. METHODS: Expression of smooth muscle α-actin (SMαA) and smooth muscle myosin heavy chain (SM-MHC) isoforms SM1 and SM2 was investigated using immunohistochemistry. RESULTS: Compared with normal lymphatic vessels, all affected lymphatic vessels in chronic lymphoedema showed marked wall thickening. In addition to increases in the numbers of rows of SMαA(+) SM1(+) SMCs in the tunica media, SMCs were also observed in the subendothelial region (tunica intima). While most intimal and medial cells were positive for SMαA and SM1, staining for SM1 and particularly SM2, a marker of mature SMCs, progressively declined in lymphatic vessels in increasingly severe lymphoedema lesions. Consequently, the SM1(+) and SM2(+) cell fractions were significantly reduced in the tunica media and intima of lymphatic vessels. CONCLUSIONS: These observations indicate that the lymphatic tunica media and tunica intima consist mainly of phenotypically modulated SMCs, and that SMCs play a key role in the development of lymphoedema.

Indocyanine Green Lymphography Findings in Primary Leg Lymphedema.

OBJECTIVES: Indocyanine green (ICG) lymphography has been reported to be useful for the evaluation of secondary lymphedema, but no study has reported characteristic findings of ICG lymphography in primary lymphedema. This study aimed to classify characteristic ICG lymphography patterns in primary lymphedema. METHODS: The study was a retrospective observational study. Thirty one primary lower extremity lymphedema (LEL) patients with a total of 62 legs were studied. ICG lymphography patterns were categorized according to the visibility of lymphatics and dermal backflow (DB) extension. Clinical demographics were compared with categorized ICG lymphography patterns. RESULTS: All symptomatic legs showed abnormal patterns, and all asymptomatic legs showed normal patterns on ICG lymphography. Abnormal lymphographic patterns could be classified into proximal DB (PDB), distal DB (DDB), less enhancement (LE), and no enhancement (NE) patterns. There were significant differences between PDB (16 patients), DDB (6 patients), LE (4 patients), and NE patterns (5 patients) in age (37.3 ± 18.3 vs. 61.8 ± 19.2 vs. 50.8 ± 27.7 vs. 29.2 ± 18.0 years, p = .035), onset of edema (23.9 ± 19.4 vs. 46.8 ± 27.0 vs. 43.0 ± 31.3 vs. 6.6 ± 14.2 years, p = .020), laterality (bilateral; 18.8% vs. 66.7% vs. 75.0% vs. 0%, p » .016), cellulitis history(56.3% vs. 100% vs. 25.0% vs. 0%, p » .007), and LEL index (292.2 ± 32.8 vs. 254.2 ± 28.6 vs. 243.3 ± 9.4 vs. 295.2 ± 44.8, p = .016). CONCLUSIONS: ICG lymphography findings in primary lymphedema could be classified into four patterns withdifferent patient characteristics.

Therapeutic strategy for lower limb lymphedema and lymphatic fistula after resection of a malignant tumor in the hip joint region: a case report.

Lymphatic fistula complicating lymphedema is thought to occur due to communication between lymph vessels and the skin, which has yet to be shown objectively. The objective of this case report is to show the pathology and treatment using simultaneous lymphatic fistula resection and lymphatico-venous anastomosis (LVA). A 40-year-old woman underwent extended resection and total hip arthroplasty for primitive neuroectodermal tumor in the right proximal femur 23 years ago. Right lower limb lymphedema developed immediately after surgery and lymphatic fistula appeared in the posterior thigh. On ICG lymphography, lymph reflux toward the distal side dispersing in a fan-shape reticular pattern from the lymphatic fistula region was noted after intracutaneous injection of ICG into the foot. We performed simultaneous lymphatic fistula resection and of LVA. Pathological examination showed that the epidermis and stratum corneum of the healthy skin were lost in the lymphatic fistula region. Dilated lymph vessels were open in this region. The examinations provide the first objective evidence that the cause of lymphatic fistula may be lymph reflux from lymphatic stems to precollectors through lymphatic perforators.

Barcelona consensus on supermicrosurgery.

The popularity of supermicrosurgery has increased dramatically over the past few years, but the lack of agreement regarding the name of the technique and its applications has caused misunderstandings among microsurgeons when trying to communicate and compare surgical procedures. We report the consensus reached on the name used to refer to supermicrosurgery techniques following the First European Conference on Supramicrosurgery held in Barcelona (Spain) on March 4-5, 2010. Present applications, advantages, and disadvantages of supermicrosurgery are discussed. It was agreed that supermicrosurgery was the most accurate name to reflect the essence of this extremely delicate technique. According to Koshima, supermicrosurgery is a technique of microneurovascular anastomosis for vessels of 0.3 to 0.8 mm and single nerve fascicles. The range of applications for this technique has increased rapidly and now includes lymphedema treatment, nerve reconstruction, replantation and reconstruction of amputated fingertips, microsurgical flap salvage, and new possibilities for free tissue transfer. Supermicrosurgery is a remarkably useful reconstructive tool that involves a great deal of skill and has a steep learning curve for the microsurgeon to master. Although it is currently performed by only a minority of microsurgeons, we consider it will be incorporated into conventional microsurgery in the near future.

Idiopathic portal hypertension and lower limb lymphedema.

Idiopathic lymphedema is a condition where lymph accumulates in subcutaneous tissue without a clear cause. Likewise, idiopathic portal hypertension is a syndrome where intrahepatic peripheral portal branch obstruction causes portal hypertension without a clear cause. We encountered a 37-year-old man with both idiopathic lymphedema and idiopathic portal hypertension. He had a history of right lower limb edema and epigastric varices since childhood with repeated cellulitis in the affected limb. Lymph accumulation and dilation of collateral lymph pathways in the right lower limb were observed by indocyanine green and lymphoscintigraphy, and a serpentine thoracic duct was observed using MRI. Idiopathic portal hypertension and idiopathic lymphedema were diagnosed, and peripheral lymphaticovenous anastomosis was performed for treatment of lymphedema. The limb circumference improved, and the frequency of cellulitis decreased. It is postulated that an abnormality in the embryonic cardinal vein before lymph vessel differentiation could be a possible mechanism of the dual pathologic conditions.

Regional diagnosis of lymphoedema and selection of sites for lymphaticovenular anastomosis using elastography.

AIM: To evaluate the use of ultrasound elastography as a basis for determining the most appropriate sites for lymphaticovenular anastomosis (LVA) for treatment of lymphoedema. MATERIALS AND METHODS: Preoperative elastography and LVA were performed in 11 patients (11 legs) with leg lymphoedema, including two cases of primary oedema and nine of secondary oedema. RESULTS: The mean number of LVAs applied per leg was 4.4 (range 3-7). The mean reduction in the leg circumference was 91.7%, and 10 of the 11 cases (90.0%) were improved. Hardness was reduced from a mean of 1.6 before surgery to 0.9 after surgery, and improvement was also noted in 10 cases (90.9%). The severity of oedema was determined in five regions in each leg, and was classified as elastography stage (ES) 0 in 11 regions, ES1 in 23, ES2 in 15, and ES3 in six. CONCLUSIONS: These results demonstrate the value of ultrasound elastography for the diagnosis of early-stage lymphoedema and determination of LVA sites. This is the first report of diagnosis of lymphoedema using elastography and the findings suggest that this procedure followed by LVA could be used as a new therapeutic method for early-stage lymphoedema.

Severe lymphedema caused by repeated self-injury.

Lymphedema is divided into primary and secondary forms. Primary lymphedema often develops in young people and may be caused by lymphvascular aplasia, hypoplasia, and hyperplasia. The most frequent cause of secondary lymphedema after lymphatic filariasis is regional lymph node dissection for treatment of a malignant tumor, and this complication occurs most frequently in middle aged or older patients. Here, we describe a relatively young patient (27 years old) in whom collecting lymph vessels in the upper limb were disrupted by repeated self-injury, with resultant lymphedema. There have been very few reports on lymphedema caused by self-induced trauma. This case report illustrates that secondary lymphedema should also be considered and evaluated appropriately when diagnosed in a relatively young patient without a history of cancer or infection.

Effect of pregnancy on lower limb lymphedema in patients treated with multisite lymphaticovenular anastomoses (MLVAS).

Lymphaticovenular anastomosis (LVA) using supermicrosurgical techniques is effective for treating and preventing progression of lymphedema. We analyzed the influence of pregnancy on LVA in five patients from a total 2179 LVA cases. Previous studies offer conflicting reports on whether pregnancy worsens pre-existing lymphedema. This is the first report on the influence of pregnancy on lower limb lymphedema previously treated by multisite LVA (mLVA). Five patients with primary (n=4) and secondary (n=1) lower leg lymphedema were analyzed for this study. Patient age ranged from 18 to 31 (average 22.6) years old with 4 right and 1 left extremities involved. Duration of symptoms ranged from one to 19 (average 7.4) years and the periods of compression therapy were from 1 to 19 years (6.6 years). Four patients had single pregnancies and one patient was multiparous with 3 pregnancies. Final follow-up ranged from 5.8 to 18 years (average 8.9 years) after the primary mLVA. All patients had normal pregnancy, birth, and no serious complications after surgeries. Following pregnancy three patients had complete functional recovery (limb volume reduction and no compression requirement), one with functional improvement (limb volume reduction but required compression), and one with no change in symptoms (not worse and continued need for compression). There were no occurrences of infection following pregnancy. Based on this case series, it is suggested that pregnancy does not worsen the pre-existing lymphedema in patients who had previously undergone mLVA. Further studies with larger number of patients are needed to confirm these results.

Rapid expansion of human adipose-derived stromal cells preserving multipotency.

BACKGROUND: Adipose-derived stromal (stem) cells (ASC) have been shown to be of great therapeutic use in pre-clinical studies in diverse fields, but a standard expansion method has not been established. We investigated the effects of an endothelial growth medium (EGM-2) on ASC, focusing on proliferation and differentiation potentials. METHODS: ASC were cultured in EGM-2 and DMEM. Doubling time and total cell number were compared between the two media. The proliferative effect of each growth factor supplemented in EGM-2 was also examined. Cultured cells in each medium were examined for surface marker expression using flow cytometry. Differentiation into the adipogenic, chondrogenic and osteogenic lineages was analyzed after culture in each medium. RESULTS: ASC cultured with EGM-2 proliferated much more rapidly (10(5) times in 2 weeks) and reached the stationary phase earlier than those cultured with DMEM. Among the supplements contained in EGM-2, only fibroblast growth factor-2 (FGF-2) significantly promoted proliferation of ASC, although the proliferative effect of FGF-2 was much less than that of EGM-2, suggesting a synergism among other supplement factors. Flow cytometry and differentiation assays suggested that ASC cultured in EGM-2 preserved immunophenotype and differentiation capacity for at least three mesenchymal lineages (adipogenic, chondrogenic and osteogenic), similar to those cultured with DMEM. DISCUSSION: The present expansion method markedly accelerates proliferation of ASC, preserving their multipotent differentiation capacities, and lays the groundwork for establishing a practical route to mega-expansion of ASC for clinical applications.

Ultrasonographic evaluation of an unusual peri-anal induration: a possible case of deep tissue injury.

High-resolution ultrasound produces good quality echo images of skin and subcutaneous lesions. Here, it was used to characterise an atypical induration, which the authors speculate might have been a deep tissue injury.

Combined vascularized fibula and peroneal composite-flap transfer for severe heat-press injury of the forearm.

A free combined vascularized fibula and peroneal composite flap was transferred to the forearm in a patient with a severely damaged forearm following a heat-press injury. The operative technique, postoperative management, and subsequent clinical course are described, and the advantages of this method are outlined. Not only can the fibula now be used as a free vascularized bone graft in simple bone defects, but further applications, such as a combined fibula and peroneal composite flap, can be employed in the treatment of severely damaged forearms.

Extended wrap-around flap for reconstruction of the finger with recurrent arteriovenous malformation.

Treatment of arteriovenous malformations of the finger is difficult because complete resection of malformations by ligation or en bloc resecting methods is impossible. We used an extended wrap-around flap consisting of a combined wrap-around flap and a dorsalis pedis flap to reconstruct the soft-tissue defects following complete resection of a recurrent malformation in the index finger. This method has two advantages: no postoperative recurrence of the malformation is expected, and the affected finger can be preserved. However, it is indicated only for malformations with no invasion to the bone and localized in one finger.

Electron microscopic observations of degeneration of human Pacinian corpuscles in amputated fingers.

Amputated human fingers were used to observe the morphologic changes in degeneration of Pacinian corpuscles, and postoperative moving two-point discrimination of the replanted fingers was examined to analyze sensory recovery after replantation. Normal corpuscles are composed of an axon terminal and inner and outer cores, resembling a sliced onion. The inner core is composed of thin, multilayered lamellar cells, and the outer core consists of multiple layers of thin perineurial cells. Based on our morphologic findings, following mitochondrial degeneration in the axon terminal, the terminal and inner core cells disappeared within 9 to 16 hours, but the outer core did not lose its structure until more than 24 hours after amputation. Collagen fibrils in the corpuscles appeared from 5 hours after amputation and periodically increased their amount up to 27 hours after amputation. Postoperative sensory recovery of the replanted fingers was significantly poorer with 9 hours or more of cold ischemia. These findings suggest that the inner core cells originating from Schwann cells degenerate at over 9 hours after amputation, and this may be related to the poor sensory recovery of replanted fingers. It also appears that the outer core cells originating from the perineurial cells in the amputated fingers survive even up to 27 hours after amputation and produce collagen fibrils in the extramatrix spaces of the outer core cells.

Combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap for the repair of wide defects of the lower leg.

The tensor fasciae latae musculocutaneous flap has great advantages for reconstruction of the abdominal wall, but the medial border of its territory is limited to the thigh. In order to expand the territory, a combined tensor fasciae latae musculocutaneous flap and sartorius musculocutaneous flap was devised. This flap was successfully used to resurface a large defect in the lower leg as a distally based musculocutaneous flap. The advantages of this flap are its extremely large territory, the fact that total necrosis of the flap cannot occur, and that as a proximally or distally pedicled flap it is suitable for large defects in the abdominal wall, lower leg, and gluteal region.

Reinnervation of denervated Pacinian corpuscles: ultrastructural observations in rats following free nerve grafts.

Nerve transection and immediate free nerve grafts using rat sciatic nerves were employed to observe the morphologic changes in periodical denervation and reinnervation of Pacinian corpuscles located on the interosseous membrane between the fibula and tibia. During periods of from 2 weeks to 20 months after the surgery, a total of 28 corpuscles were obtained under an operating microscope and processed for morphologic analysis using light and electron microscopes. Based on our morphologic findings, normal corpuscles were composed of an axon terminal and inner and outer cores. The axon terminal disappeared within 2 weeks after the nerve grafts, but the original inner and outer core cells remained for up to 20 months. In addition, a small number of collagen fibrils was observed between the inner and outer core cells. After 4 months, multiple axon terminals began to regenerate in the inner core. From 7 to 20 months, these axon terminals in some corpuscles developed a structure resembling that of normal terminals. Some of these terminals were located in the center of the inner core, but a few were in contact with the outside of the inner core. The production of collagen fibrils in denervated corpuscles was periodically activated in the intercellular spaces. These findings suggest that the morphologic changes in denervated corpuscles correspond to those in denervated nerves. Inner core cells, which are continuous with Schwann cells, remain in their original condition in denervated corpuscles until regenerating nerves enter the inner core and are essential for corpuscle regeneration, because they may produce some trophic substances that induce the regeneration of multiple axon terminals.(ABSTRACT TRUNCATED AT 250 WORDS)

Muscle stapling technique for free muscle transfer to the face.

Free muscle transfer for facial reanimation can be facilitated by the use of a linear gastrointestinal stapler. This technique not only offers reliable muscle insertion at the recipient site but also helps to provide an adequate motor unit by facilitating safe muscle debulking, splitting, and tailoring.

One-stage reconstruction of established facial paralysis using a rectus abdominis muscle transfer.

A free vascularized rectus abdominis muscle graft with a long motor nerve was used for reconstruction of unilateral established facial paralysis in one stage. Regarding the procedure, the pedicle vessels were anastomosed to the recipient vessels in the ipsilateral face, and the motor nerve of the muscle was sutured to the contralateral facial nerve. The advantages of using the rectus abdominis muscle are as follows: (1) the muscle is very thin, not bulky, (2) the muscle can be split easily to reduce the volume, (3) the intercostal nerve is long enough (more than 20 cm) to reach the contralateral facial nerve for suturing, (4) the pedicle vessels are large and long, (5) it is possible to carry out simultaneous operations with two teams, and (6) the donor-site morbidity is minimal. The disadvantages of this method are that complicated surgical dissection is required to obtain a motor nerve and that a postoperative abdominal hernia may occur.

Sixty cases of partial or total toe transfer for repair of finger losses.

Our experience with partial or total toe transfers for the reconstruction of finger deficits is presented. Sixty-one toes were transferred to reconstruct finger deficits in 60 patients. The transfers from the big toe consisted of 3 vascularized whole-nail grafts, 4 onychocutaneous flaps which included the nail and a skin flap from the toetip, 16 thin osteo-onychocutaneous flaps, 4 wrap-around flaps, and 3 combined wrap-around and dorsalis pedis flaps. The transfers from the second toe consisted of 6 trimmed toetips including the nail, 16 second toes, 1 combined second toe and a dorsalis pedis flap, and 1 second toe and third toe. The other transfers mainly consisted of other flaps, including a hemipulp flap and a first web space flap. Regarding the transfers from the big toe, vascularized nail grafts and onychocutaneous flaps were found to be most suitable for the treatment of total nail loss, thin osteo-onychocutaneous flaps for distal phalangeal loss of the thumb, wrap-around flaps with a vascularized iliac bone graft for thumb loss above the metacarpal joint, and the combined wrap-around and dorsalis pedis flaps for a total thumb deficit. Regarding the transfers from the second toe, the trimmed toetips including the nail were most suitable for claw nail deformities, the second toe was most suitable for finger loss except for the thumb with the proximal interphalangeal joint, and the combined second toe and dorsalis pedis flap was most applicable for a total thumb deficit including thenar skin loss.