A Simplified Algorithmic Approach to Vulvar Reconstruction According to Various Types of Vulvar Defects.

OBJECTIVE: Various surgeons adopt various vulvar reconstruction methods for different types of vulvar defects to restore anatomical structures. Vulvar reconstruction has relatively few references as it is performed in many different ways. Our report aimed to create a simplified reconstruction algorithm that can be used to select the reconstruction flap and to compare clinical outcomes. METHODS: The patients who underwent vulvar reconstruction between April 2017 and May 2020 were retrospectively reviewed. The reconstruction flap was selected according to a suggested algorithm, which accounted for the defect location depending on the vulvo-thigh junctional crease-the visual landmark of the inferior pubic ramus-and proper perforator location. Postoperative surgical complications, functional outcomes, and oncologic outcomes were analyzed according to the histologic and flap types. RESULTS: Forty-seven patients underwent reconstruction with 31 internal pudendal artery perforator flaps (66%) and 16 profunda artery perforator flaps or transverse upper gracilis flaps (34%). The histologic type included 21 extramammary Paget disease (44.7%), 20 squamous cell carcinoma (42.6%), and 6 other types (12.8%). Postoperative complications, including wound and functional complications, occurred in 10 patients (21.3%). There were more cases of wound complications with profunda artery perforator flaps and transverse upper gracilis flaps (37.5%) than those with internal pudendal artery perforator flaps (12.9%) (P = 0.04). There were 7 cases (14.9%) of 2-year oncologic recurrence with no significant differences in terms of histologic or flap types. CONCLUSIONS: According to our suggested simplified algorithm, various types of flaps resulted in reliable surgical outcomes with minimal complication rates and acceptable functional and oncologic outcomes, and the primary goals of vulvar reconstruction were achieved effectively. Using our algorithm, selection of the reconstruction method could be simplified and specified despite the complexity of vulvar defects.

Lipedema associated with Skin Hypoperfusion and Ulceration: Soft Tissue Debulking Improving Skin Perfusion.

Lipedema is a progressive connective tissue disease with enlargement of adipose tissue, fibrosis, fluid collection, and dermal thickening. Herein, we present a case of lipedema associated with skin hypoperfusion and ulceration in which soft tissue debulking with liposuction improved patients' symptoms. A 39-year-old female presented with asymmetric progressive initially unilateral lower limb swelling with severe pain with subsequent skin ulceration. Conservative management failed to improve her condition. After excluding other causes and detailed radiologic investigation, lipedema was diagnosed with an associated impaired skin perfusion. Trial of local wound care and compression therapy failed to improve the condition. Subsequent soft tissue debulking with circumferential liposuction and ulcer debridement and immediate compression showed dramatic improvement of the symptoms and skin perfusion. The unique nature of this case sheds light on lipedema as a loose connective tissue disease. Inflammation and microangiopathies explain the associated pain with hypoperfusion and ulceration being quite atypical and in part might be related to the large buildups of matrix proteins and sodium contents leading to fragility in microvessels with frequent petechiae and hematoma and subsequent tissue ischemia. Conservative measures like compression therapy plays a significant role in disease course. Surgical debulking with liposuction was shown to be efficacious in reducing the soft tissue load with improvement in limb pain, edema, circumference, and skin perfusion that was seen in our patient. Lipedema is a frequently misdiagnosed condition with disabling features. Skin involvement in lipedema with potential hypoperfusion was shown and it requires further investigation.

Asian rhinoplasty using a thin rib cartilage graft and ultrafine diced cartilage wrapped in fascia: A comparative study between septal cartilage graft and rib cartilage graft.

BACKGROUND: A 1-2-mm thin rib cartilage graft was used as a septal extension graft to overcome the drawbacks of traditional rib cartilage rhinoplasty, which often results in a stiff nasal tip. The remaining rib cartilage was placed on the nasal dorsum as an ultrafine diced cartilage wrapped in fascia (UDCWF) graft. This study aimed to assess the stability of thin rib cartilage grafts and measure the resorption rate of the UDCWF graft. METHODS: This retrospective study included 53 patients who underwent rhinoplasty with septal extension grafting and nasal dorsum augmentation using a septal cartilage (SC group) or rib cartilage (RC group) graft between June 2017 and June 2020. The nasal length, tip height, sellion height, and nasolabial angle in the preoperative, immediate postoperative, and long-term postoperative periods were analyzed using three-dimensional photogrammetry. RESULTS: A total of 26 patients received rib cartilage grafts and 27 patients received septal cartilage grafts. The RC group showed greater maintenance of tip height, nasal length, and tip derotation over time. The relapse ratio in tip height was -3.3 ± 1.6% and -8.4 ± 4.3% in the RC and SC groups, respectively (p = 0.001). The resorption rate of the UDCWF graft was -7.5 ± 3.6% and -7.8 ± 2.3% at the sellion and rhinion, respectively. CONCLUSIONS: The thin rib cartilage provided sufficient intrinsic strength to maintain tip height and tip rotation. It can be an effective alternative to rhinoplasty in Asians with features such as thick skin and a short nose. Moreover, the UDCWF graft exhibited an approximately 7.5% resorption rate, leading to lower probabilities of dorsal irregularity and stepping deformity.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients.

Background This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p = 0.659, r = - 0.041), and amount of limb volume reduction ( p = 0.454, r = - 0.070) showed no statistical significance. Conclusion The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Using Lymphovenous Anastomosis and Lymph Node to Vein Anastomosis for Treatment of Posttraumatic Chylothorax with Increased Thoracic Duct Pressure in 3-Year-Old Child.

Chylothorax is a rare disease and massive lymph fluid loss can cause life-threatening condition such as severe malnutrition, weight loss, and impaired immune system. If untreated, mortality rate of chylothorax can be up to 50%. This is a case report of a 3-year-old child with iatrogenic chylothorax. Despite conservative treatment and procedures, like perm catheter insertion, the patient failed to improve the respiratory symptoms over 3 months of period. As an alternative to surgical option, such as pleurodesis and thoracic duct ligation which has high complication rate, the patient underwent lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA). Follow-up at fourth month showed clear lungs without breathing difficulty despite perm catheter removal. This is the first report to show the effectiveness of LVA and LNVA against iatrogenic chylothorax.