Carotid artery and soft tissue reconstruction with superficial femoral artery-sartorius muscle-anteromedial thigh chimeric free flap: A case report and review of the literature.

Tumoral involvement of the carotid artery may require en-bloc resection in order to achieve a better regional control. Among the carotid reconstruction methods at disposal, autologous tissues appear to be more reliable in cases with high risk of infection and poor tissue healing like in radiated necks. We describe a case of a 55 year old man, who suffered from recurrent squamous cell carcinoma in the neck region, invading the common carotid artery. After en-bloc resection of the tumor together with skin, internal jugular vein, vagus nerve and common carotid artery, carotid reconstruction was performed with a flow-through chimeric flap based on superficial femoral vessels (15 cm). After resection of the tumor, the flap was used to replace the soft tissue defect (23 × 12 cm). Anteromedial thigh skin paddle (8 × 5 cm) and sartorius muscle (12 × 3 cm) were included in the flap. The superficial femoral vessels were reconstructed with 8-mm ringed polytetrafluoroethylene graft interposition. Thanks to an accurate surgical planning and a 2-team approach, the ischemia time of the leg was 42 min and there were no limb ischemia nor pathologic neurological signs after surgery. During the 12-month follow up, no other complication was registered. In our experience, microsurgical carotid reconstruction represents a reliable option with important advantages such as resistance to infection, optimal size matching, and good tissue healing between the irradiated carotid stump and the vascular graft.

Clear Sinus Sign on Head CT Scan: Reliable Criterion to Exclude Paranasal Sinus Fracture.

PURPOSE: The clear sinus sign has been described in facial computed tomography (CT) as an indication of the absence of fluid in the paranasal sinuses. It is a highly reliable criterion to exclude fracture involving the paranasal sinus wall. Very scarce data on this sign on head CT scan is currently available. We conducted the present study to assess the usefulness of the clear sinus sign on head CT scan to exclude paranasal sinus fracture. MATERIALS AND METHODS: A retrospective cross-sectional review of the medical records and head and facial CT images was performed for 80 trauma patients with a total of 640 paranasal sinuses. The presence and absence of paranasal sinus fracture was recorded and analyzed. RESULTS: The clear sinus sign was found in 207 paranasal sinuses (32.3%) on head CT, and none of these had a paranasal sinus fracture (P < .001). CONCLUSIONS: The presence of the clear sinus sign on head CT scans is an excellent indication for exclusion of a paranasal sinus fracture in trauma patients.

Optimizing survival of large fibula osteocutaneous flaps for extensive full-thickness oromandibular defects: A two-stage approach with temporary orocutaneous fistula.

INTRODUCTION: Composite and large head and neck defects requiring extensive skin-mucosa coverage are often reconstructed by combining flaps. Herein, we present a simple and reliable two-stage fibula osteocutaneous (FOC) flap technique to improve the survival of a large skin paddle for oromandibular reconstructions. METHODS: From October 2011 to September 2016, 47 patients with through-and-through oromandibular defects were reconstructed using FOC flaps with large skin paddles. To ensure optimum survival of skin paddles, temporary orocutaneous fistula were left in place and closed during the second stage operation via de-epithelialization of the skin paddle and suturing of mucosa. Demographic data, operative details, and postoperative complications were recorded. RESULTS: The skin paddle dimensions ranged from 20 to 31.5 cm in length and 12 to 17 cm in width with an average area of 430.4 cm2 (range 300-504). The average time between the two stages and hospital stay were 10 days and 14 days, respectively. Complications at the donor site included wound dehiscence (n = 3, 6.4%), partial skin graft loss (n = 3, 6.4%) and hematoma (n = 2, 4.3%). Recipient site complications included two (4.3%) early postoperative venous congestions that resolved after elevation and three (6.4%) partial skin flap necrosis (less than 5% surface area). All complications resolved with bedside conservative management. There was only one take-back for evacuation of recipient site hematoma (2.1%) but no flap loss. CONCLUSION: Two-staged large skin paddle FOC flaps can simplify reconstruction of extensive oromandibular defects by improving the reliability of the sizable skin paddle and negating the need for a second flap.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty-Where We Are Today: A Systematic Review and Meta-Analysis.

INTRODUCTION: There is an increased need for evidence-based practices in male-to-female (MtF) transgender vaginoplasty. Although there are a multitude of surgical techniques, there is a paucity of data comparing these procedures. A systematic review of retrospective studies on the outcomes of MtF vaginoplasty was conducted to minimize surgical complications and improve patient outcomes for transgender patients. METHODS: Applying the Preferred Reporting Items for Systematic Review and Meta-Analysis, a comprehensive search of several databases from 1985 to November 7, 2017, was conducted. The databases included PubMed, Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Web of Science. The resulting publications were screened, and those that met our specified inclusion/exclusion criteria were analyzed. The DerSimonian and Laird random-effects model was used to pool complications and patient-reported outcomes. RESULTS: A total of 471 articles were initially identified, of which 46 met our eligibility criteria. A total of 3716 cases were analyzed. Overall incidence of complications included the following: 2% (1%-6%) fistula, 14% (10%-18%) stenosis and strictures, and 1% (0%-6%) tissue necrosis, and 4% (2%-10%) prolapse (upper and lower limits of the 95% confidence interval). Patient-reported outcomes included a satisfaction rate of 93% (79%-100%) with overall results, 87% (75%-96%) with functional outcomes, and 90% (79%-98%) with esthetic outcomes. Ability to have orgasm was reported in 70% (54%-84%) of patients. The regret rate was 1% (0%-3%). The length of the vaginal cavity was 12.5 cm (6.3-4.4 cm). CONCLUSIONS: Multiple surgical techniques have demonstrated safe and reliable means of MtF vaginoplasty with low overall complication rates and with a significant improvement in the patient's quality of life. Studies using different techniques in a similar population and standardized patient-reported outcomes are required to further analyze outcomes among the different procedures and to establish best-practice guidelines.

Application of extended bi-pedicle anterolateral thigh free flaps for reconstruction of large defects: A case series.

BACKGROUND: The anterolateral thigh flap is a workforce flap in reconstructive surgery, however, variations in it is vascular anatomy are not uncommon. These variations may affect flap design and survival, especially when large flaps are required. In some anatomical variants the anterolateral thigh flap is supplied by two separate dominant pedicles, and in these cases a bi-pedicle modification may be necessary to ensure complete flap viability. The aim of this report is to evaluate the outcomes, and present our approach in using bi-pedicle anterolateral thigh flaps as a method to reduce the risk of partial flap necrosis when reconstructing sizeable soft tissue defects. PATIENTS AND METHODS: From October of 2013 to November of 2015, seventeen patients were treated with extended bi-pedicled ALT flaps for reconstruction of large defects (16 to 25 × 8 to 13 cm). Following doppler mapping of the lateral thigh perforators, an anterior incision was made. When a distinct oblique branch (OB) was present and the perforators of the descending branch of the lateral circumflex femoral artery (d-LCFA) were small, the large bi-pedicle ALT flaps were harvested based on both the oblique branch and the d-LCFA pedicle. We evaluated the perfusion of the flap using only one pedicle by clamping alternately the OB and the d-LCFA. After flap harvest, we performed two end-to-end venous anastomosis between the lateral circumflex femoral vein and a recipient vein, and the oblique branch vein with a second recipient vein. End to end arterial anastomosis were performed between the two pedicles and two recipient arteries. Y-shaped interposition vein graft (YVG) was applied when single recipient artery was available for revascularization. The flaps were used for scar contracture, chest wall, lower and upper extremity soft tissue defects, breast, scalp, oral cancer, and esophageal reconstruction. RESULTS: The flaps size were 18 to 26 × 10 to 14 cm. For all seventeen patients the reconstructive goals were achieved with complete survival of the large ALT flaps with no events of partial necrosis or failure. We reported one case of re-exploration of a congested flap due to venous thrombosis, which was successfully salvaged. CONCLUSION: Bi-pedicled ALT flaps could be a considered as a valuable option when a second pedicle is encountered and large flaps are required.

Normative Data of the Interorbital Distance in Thai Population.

The incidence of the patients with craniofacial anomalies was high in southeast-Asian countries, for example, fronto-ethmoidal encephalo-menigocele or craniosynostosis. These craniofacial anomalies usually involve orbits, so a surgical orbital reconstruction is always required.Various methods have been used in the past to indirectly analyze the craniofacial region. Plain skull radiography, anthropometry, and cephalometry provided the limited information of interorbital distance in terms of accuracy whereas the interorbital distance is crucial to be reconstructed, increasing or decreasing. The accurate normal interorbital distance which grows by age as other craniofacial structures is the important data in the part of interorbital and orbital reconstruction. To date, the normative data of the bony interorbital distance among Thai population have not been established.The purpose of this study is to provide normal values and the growth patterns of the bony interorbital distances and other dimensions of the orbit according to age among Thai population through the axial computed tomography. Comparisons can then be made between normal values and those for an individual patient or those for a group of patients, for example, those with front-ethmoidal meningoencephalocele, Crouzon, or Treacher-Collins syndrome, or among values for individual patients at different time intervals.A retrospective study of computed tomography (CT) scan series of 698 normal orbits from 349 skeletally normal subjects (202 men and 147 women) was enrolled. The age range of the patients was 0 to 21 years (mean, 10.2 years; SD, 5.8 years). A series of 12 measurements were obtained from the CT scans of each subject. All CT images were obtained from patients who underwent CT of the facial bone, brain, and orbits at the Department of Radiology of 3 big hospital in Bangkok-Ramathibodi, Samitivej Srinakarin, and Bangkok hospital-since 2010 to 2015.The normal measurement values in the orbital region through the CT images, as the normal periorbital growth curve, will help improving diagnostic accuracy, staging of reconstruction, precision of corrective surgery, and follow-up of the Thai patients with craniofacial abnormalities such as front-ethmoidal meningoencephalocele, hypertelorism. These data may also apply to the related population in the southeast-Asian countries.

A head-to-head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6-year single center experience.

Between 2010 and 2016, 110 patients with extremity lymphedema underwent vascularized lymph node (VLN) transfer: groin (G-VLN = 20), supraclavicular (SC-VLN = 54), and right gastroepiploic (RGE-VLN = 36) open and laparoscopic approach. Herein, we discuss the pearls and pitfalls for VLN harvest and compare donor site morbidity and complications. Lymphatic leakage: G-VLN (n = 1) and SC-VLN (n = 1) and one hematoma: SC-VLN were found. Laparoscopic harvest of the RGE-VLN reduces donor site morbidity. However, surgeons experience is imperative to minimize donor site morbidity and complications. J. Surg. Oncol. 2017;115:37-42. © 2016 Wiley Periodicals, Inc.

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck.

BACKGROUND: Reconstruction in a vessel-depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel-depleted neck. METHODS: Between July 2010 and June 2016, nine patients with a vessel-depleted neck underwent secondary head and neck reconstruction using the retrograde TCA as recipient vessel for microanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previous bilateral neck dissections and all, except one, had also received radiotherapy. Indications included neck contracture release (n = 3), oral (n = 1), mandibular (n = 3) and pharyngoesophageal (n = 2) reconstruction necessitating free anterolateral thigh (n = 3) and medial sural artery (n = 1) perforator flaps, fibula (n = 3) and ileocolon (n = 2) flaps respectively. RESULTS: There was 100% flap survival rate with no re-exploration or any partial flap loss. One case of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbidity during the follow-up period. CONCLUSIONS: In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option for complex secondary head and neck reconstruction in selected patients.

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes.

BACKGROUND: Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema. METHODS: From January 2012 to January 2013, 10 consecutive female patients, average age 54.8 years, with International Society of Lymphology stage II-III extremity lymphedema refractory to conservative management were included. Five patients had upper limb breast cancer-related lymphedema and five patients had lower limb pelvic cancer-related lymphedema. All patients underwent laparoscopic harvest of the right gastroepiploic lymph node flap, transferred to the wrist and ankle as recipient sites. Flaps were covered with a small skin graft taken from the thigh. Perioperative assessment included physical exam, photography, circumference measurements, CT scans, lymphoscintigraphy, and Lymphedema Quality of Life (LYMQOL) questionnaire. Clinical and CT evaluation of donor-site morbidity were performed. RESULTS: The flap survival rate was 100%, with a mean harvest time of 32 minutes and total operating time of 164 minutes. One case required regrafting for skin graft loss. The mean limb reduction rate was 39.5% at a mean follow-up of 14.7 months. Perioperative lymphoscintigraphy demonstrated transferred lymph node viability and lymphatic transport improvement. LYMQOL showed a 2.6-fold quality-of-life improvement (P < 0.01). No donor-site morbidity was encountered. CONCLUSIONS: The use of the laparoscopically harvested right gastroepiploic lymph node flap may be a safe technique that improves limb measurements and quality of life in extremity lymphedema patients. © 2015 Wiley Periodicals, Inc. Microsurgery 37:197-205, 2017.

The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema.

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.

The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.

BACKGROUND: Surgical options for breast reconstruction include alloplastic and autogenous reconstructions. In autologous cases where the abdomen is not a suitable primary donor site, secondary donor sites such as the thigh or buttock are considered. The aim of this report is to describe a novel approach, the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap, aimed at medium to large volume breast reconstruction, with a single donor site used per breast. METHODS: Between January 2011 and June 2013, 32 consecutive unilateral immediate breast reconstruction cases were performed using free flaps. In nine cases, patients had previously undergone abdominal surgery, therefore abdominal flaps were excluded and TUGPAP flaps were performed. The TUGPAP flap consisted of the combination of two well-described flaps: the transverse upper gracilis (TUG) and the profunda artery perforator (PAP) flap. All TUGPAP flaps were based on two pedicles: the ascending branch of the medial circumflex femoral artery (MCFA) for the TUG component, and the profunda artery perforator itself for the PAP component. RESULTS: The mean size of the harvested skin paddle was 28.6 × 8 cm2 (range, 27 × 7 cm2 to 30 × 9 cm2). The average length of the TUG flap pedicle was 7 cm (range, 6-8 cm) and the PAP flap pedicle was 9 cm (range, 8.5-10 cm). The flap survival rate was 100% with no re-exploration, and no partial flap loss. Post-operatively there was one case of persistent donor site seroma, which was managed conservatively. CONCLUSION: With appropriate patient selection and surgical technique the TUGPAP flap could be a valuable option as an alternative method for autologous breast reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema.

Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.

Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel.

BACKGROUND: Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. PATIENTS AND METHODS: We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio-venous malformation, Paget's disease, squamous cell carcinoma, and Fournier's gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. RESULTS: All the flaps had 100% viability without partial loss. Mean follow-up was of 7.4 months (range 4 - 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. CONCLUSION: The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals.

Reconstruction after orbital exenteration using gracilis muscle free flap.

BACKGROUND: Orbital exenteration (OE) is a disfiguring procedure, which typically includes the removal of the entire eyeball including the globe, extraocular muscles, and periorbital soft tissues after malignancies excision or trauma. Several methods of orbital reconstruction have been attempted with varying success. In this report, we analyze results of the use of gracilis muscle free flap for reconstruction of OE defects and its feasibility for prosthetic rehabilitation. METHODS: Nine consecutive patients treated at the China Medical University Hospital of Taichung during January 2009 to January 2013, who had gracilis free flap reconstruction after OEs, were retrospectively reviewed. Cancer in six patients and trauma in remaining three patients was the cause for OE. RESULTS: Nine patients who underwent reconstruction with gracilis free tissue transfer had a successful outcome. There was not any donor or recipient site morbidity; however, one patient was deceased during follow-up period due to metastasis. The mean follow-up period was 23.5 months. Cosmetic results were acceptable both to patients and to surgeons. CONCLUSIONS: Gracilis free flap to repair OE defects may be a safe alternative for reconstruction. It provides a larger volume of well-vascularized tissue, greater placement flexibility, and minor donor site morbidity without any significant functional deficit.

Modified Charles procedure and lymph node flap transfer for advanced lower extremity lymphedema.

INTRODUCTION: Treatment of advanced lymphedema remains a challenge in reconstructive surgery. Microsurgical techniques seem to be effective in early stage lymphedema, however in advanced stages their role is not well established. In this study, we present a novel approach for advanced lymphedema combining excisional procedure (Charles) with transferring lymph node flap. PATIENTS AND METHOD: From 2010 to 2013, 24 patients (18 women, six men, mean age 53 years old) presented with late stage of lower extremity lymphedema. The modification of Charles procedure consisted of preserving the superficial venous system of the dorsum of the foot and the lesser saphenous vein, which were used for the venous anastomosis of the transferred lymph node flap. In 11 patients we transferred the inguinal lymph node flaps from the contralateral site, meanwhile in 13 patients supraclavicular lymph node flaps were used. RESULTS: Maximum reduction of the lymphedema was achieved. No major complication was detected postoperatively. There were two patients with partial loss of the skin graft necessitated re-grafting. All the lymph node flaps survived well. The patients resumed normal daily activities within a period of 2 months. The mean follow-up was 14 months (3-26 months). During this period, no recurrence of the lymphedema was observed. CONCLUSION: The combination of the modified Charles procedure with vascularized transferring of lymph node flap is an effective method for treatment of advanced stage lymphedema.

Effects of Cutting Planes on Costal Cartilage Warping.

BACKGROUND: Autogenous costal cartilage becomes a favorable choice for nasal reconstruction and complicated aesthetic rhinoplasty, due to its ample supply, sufficient for most patients. However, a notable drawback is the potential for warping. Our study aims to identify cutting planes that minimize warping. MATERIALS AND METHODS: Two hundred and seven costal cartilage grafts were obtained by slicing the extracted costal cartilages from 10 fresh cadavers, along three main planes: cephalocaudal, anteroposterior, and parallel to the synchondrosis plane. Each of these major planes was further divided into grafts taken from both the central and peripheral portions. Furthermore, both subgroups were categorized into three thicknesses: 1mm, 2mm, and 3mm. The warping angles of all grafts were then compared at various time intervals after the initial cutting. RESULTS: Cephalocaudal cuts exhibited significantly greater warping than other planes. Anteroposterior cuts displayed the least warping, although this difference lacked statistical significance. Peak warping occurred at 30 minutes. Certain grafts continued to warp even at 1 month. Central grafts had less warping than peripheral ones, though not statistically significant. CONCLUSIONS: Cephalocaudal cuts yielded the highest warping angle. Surgeons seeking thin (< 3 mm) straight grafts should opt for anteroposterior or parallel to synchondrosis planes. Thicker grafts (> 3 mm) can be cut in the cephalocaudal plane with an acceptable warping angle, close to parallel with the synchondrosis plane. For curved cartilage, thin cephalocaudal cut is recommended. Additionally, we suggest placing the cartilage in normal saline for at least 30 minutes, allowing for maximum warping to occur.

Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites.

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.