Lymphedema and concomitant venous comorbidity in the extremity: Comprehensive evaluation, management strategy, and outcomes.

BACKGROUD: The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions. METHODS: Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and concomitant vascular lesions treated with vascularized lymph node flaps were reviewed. The patients had vascular interventions discovered during workup for lymphedema surgery. Outcomes were assessed using circumferential difference (CD) and circumferential reduction rate (CRR) at 12-month and final follow-up visits. RESULTS: Vascular lesions (n = 15) included proximal arterial occlusion ( n = 1), vascular malformation ( n = 2), and proximal venous compression/stenosis ( n = 12). Concomitant vascular lesions had an incidence of 15.8% in patients that underwent vascularized lymph node transfers (VLNTs). We had 100% VLNT survival rate and average number of episodes of cellulitis after VLNTs decreased significantly ( p < 0.05). The CRR for the below knee/elbow measurement at 12-months follow-up was significantly higher for patients that underwent vascular intervention for venous lesions before VLNT instead of concurrently or after (23.7% vs 12.2%, P = 0.23). Final mean CRR was 23.7% and 12.2% respectively. CONCLUSION: Preoperative workup of concomitant vascular lesions is important for lymphedema management. We suggest appropriate vascular intervention should be done prior to VLNT to maximize the short-term and long-term outcomes.

Negative pressure wound therapy for the management of flaps with venous congestion.

PURPOSE: The aim of this report is to evaluate the utility of negative pressure wound therapy (NPWT) for rescuing flaps with venous congestion not attributable to a mechanical etiology and that cannot be surgically salvaged. PATIENTS AND METHODS: A total of 12 patients suffered from partial or total flap congestion after pedicle or free-flap reconstruction was included. All patients underwent NPWT between 3 and 10 days postoperatively. RESULTS: All congested flaps survived after the application of NPWT. Nine patients suffered partial flap loss and this was addressed through debridement of the devitalized tissue and primary closure. Three patients required blood transfusions during the course of their management. All patients presented complete coverage of the defects without further problems in the flaps after the treatment. CONCLUSION: NPWT may be considered an alternative management strategy for flaps, which has undergone venous congestion not due to a mechanical cause. © 2016 Wiley Periodicals, Inc. Microsurgery 36:467-473, 2016.

Musculoseptocutaneous Perforator of Anterolateral Thigh Flap: A Clinical Study.

BACKGROUND: The anterolateral thigh flap is one of the most useful workhorse flaps for microsurgical reconstruction. However, it can pose a great challenge to surgeons because of its anatomical variability. As the technology advances, not only septocutaneous or musculocutaneous courses of anterolateral thigh perforators but also a hybrid musculoseptocutaneous perforator pattern have been identified on computerized imaging and on cadaveric study. However, there is a paucity of clinical study in the literature. The aim of this investigation was to identify the features of this pattern. METHODS: All patients undergoing anterolateral thigh flap harvest between September of 2017 and May of 2018 performed by a single surgeon are included. Every pulsatile perforator was dissected to document its location on the thigh, emerging location (septum/muscle), size, course, and origin. RESULTS: Thirty-seven patients with 115 perforators were identified. Ten percent of perforators were septocutaneous, 37 percent were musculoseptocutaneous, and 52 percent were musculocutaneous. Forty-seven percent of perforators emerged on the septum between the rectus femoris and the vastus lateralis. Eighty-one percent of patients had one or more perforators in the "hot zone." Medium and large perforators were more frequently located in the proximal and hot zones. All perforators originated from the vascular tree of the lateral circumflex femoral artery, with 10 percent originating from the transverse branch, 28 percent originating from the oblique branch, and 62 percent originating from the descending branch. CONCLUSIONS: A high proportion of musculoseptocutaneous perforators were identified. The clinical relevance of this is to be very cautious on the skin paddle design while harvesting the flap.

Synchronous reconstruction of esophageal defect and voice with J-flap after laryngopharyngectomy: Indications and outcomes.

BACKGROUND: The primary reconstruction goal for patients with laryngopharyngectomy is the restoration of esophagus, whereas voice reconstruction is less readily reconstructed. J-flap is a novel surgical technique designed to reconstruct voice and esophagus synchronously, permitting functional rehabilitation of aerodigestive tract after laryngopharyngectomy. OBJECTIVES: This study aims to present indications, surgical steps, and outcomes of an innovative technique for synchronous reconstruction of the esophagus and voice tube with a free thigh flap (J-flaps). METHOD: Single-center study from 2011 to 2017 recruiting patients with hypopharyngeal cancer needing laryngopharyngectomy and J-flaps reconstruction. Patient details were analyzed, and surgical outcomes were examined. RESULTS: 20 patients were recruited with an average age of 61. Tumor staging was IIB or above. The average follow-up period was 15 months. 65% of these patients resumed a full diet. The row phonation rate was 75%. The average maximum phonation time was 8.9 s, and the average number of counting in a breath was 14. CONCLUSIONS: Most patients achieved a conversational level of speech capacity with a humanoid voice. J-flap can be utilized safely, supporting the social re-integration of these patients with their new voice.