Nylon Suture Loop for Tagging Lymphatic Channels during Lymphaticovenular Anastomosis.

Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely. Method We propose a novel technique, which is used in LVA for tagging of lymphatic vessels, with the use of a nylon 6-0 suture and micro-ligaclip. Results We have successfully performed 78 LVAs in 26 cases with this method. The average lymphatic vessel size was 0.3 mm (0.15-0.8 mm). Conclusion This novel technique to implement the use of a nylon suture with a micro-ligaclip to use as a vessel loop for lymphatics has not been previously described in the literature. It is a useful technique that we find beneficial to lymphatic identification through tagging of the lymphatic channels, contributing to greater success in each anastomosis.

Human tissues contain CD141hi cross-presenting dendritic cells with functional homology to mouse CD103+ nonlymphoid dendritic cells.

Dendritic cell (DC)-mediated cross-presentation of exogenous antigens acquired in the periphery is critical for the initiation of CD8(+) T cell responses. Several DC subsets are described in human tissues but migratory cross-presenting DCs have not been isolated, despite their potential importance in immunity to pathogens, vaccines, and tumors and tolerance to self. Here, we identified a CD141(hi) DC present in human interstitial dermis, liver, and lung that was distinct from the majority of CD1c(+) and CD14(+) tissue DCs and superior at cross-presenting soluble antigens. Cutaneous CD141(hi) DCs were closely related to blood CD141(+) DCs, and migratory counterparts were found among skin-draining lymph node DCs. Comparative transcriptomic analysis with mouse showed tissue DC subsets to be conserved between species and permitted close alignment of human and mouse DC subsets. These studies inform the rational design of targeted immunotherapies and facilitate translation of mouse functional DC biology to the human setting.

A Surgical Approach to the Harvest of the Vascularized Submandibular and Submental Lymph Node Flap: The "Through-the-Gland" Dissection Technique.

BACKGROUND: Extremity lymphedema is a pathological condition resulting from absence of lymph nodes and disease of lymphatic vessels, often due to oncologic clearance of lymph nodes. In recent years, vascularized lymph node transfer has become a rapidly emerging method of lymphatic reconstruction shown to lead to lymphatic regeneration. In particular, lymphatic flaps based on the submental artery have shown good results with its favorable donor site and available nodes. The lymph nodes here are in close relation to the submandibular gland and require careful dissection around and through the gland for safe harvest. We studied this region of the neck and describe the blood supply to the lymph nodes, their variable positions in relation to the gland, and our technique of dissecting through the submandibular gland while keeping the lymph nodes' hilar blood supply intact. METHODS: We dissected 2 cadaver heads (4 sides of the neck) to study the submandibular and submental lymph nodes, where to locate them in relation to the submandibular gland and how best to dissect through the submandibular gland for access while keeping the hilar supply intact. We applied this knowledge in 6 clinical cases and provide a brief description of our "through-the-gland" dissection technique. RESULTS: The submandibular lymph nodes may lie (1) superficial and posterior to the gland, (2) between the superficial and deep parts of the submandibular gland, or (3) anteriorly and submental. They are classified as superficial, deep, and submental, respectively. The through-the-gland dissection technique gave the surgeon improved access and exposure to the lymph nodes. It also facilitated safer dissection because their hilar blood supply is well visualized. CONCLUSIONS: The through-the-gland technique of harvesting vascularized submandibular lymph node flaps is a safe technique that allows the surgeon to clearly identify and preserve blood supply of lymph nodes.

Hilar Vessels of the Submandibular and Upper Jugular Neck Lymph Nodes: Anatomical Study for Vascularized Lymph Node Transfer to Extremity Lymphedema.

OBJECTIVES: Vascularized lymph node transfer for lymphedema is an emerging method of treatment. Vascularized lymph nodes have been harvested from a number of donor sites, that is, groin, axilla, and neck. There is a concern that harvesting nodes from the groin and axilla may lead to donor site lymphedema. This risk is greatly reduced in harvesting from the neck due to the abundant supply of lymph nodes here. In this cadaver study, we describe the submandibular and upper jugular groups of lymph nodes, demonstrate their hilar vessels, their source pedicles and drainage veins, quantified and qualified these groups of lymph nodes and their relationship to surrounding structures. METHODS: Five fresh adult cadaver necks (10 sides) were dissected looking at the submandibular and upper jugular neck nodes under the microscope. We carried out vascularized lymph node transfer of upper jugular nodes from the neck to the groin of 1 patient with stage II lower extremity lymphedema and transferred vascularized submandibular nodes from the neck to the upper arm in 1 patient with stage II upper extremity lymphedema. RESULTS: There was a mean of 3.2 (range, 1-5) lymph nodes in the submandibular group and a mean of 4.1 (range, 2-6) lymph nodes in the upper jugular group. The submandibular nodes were perfused by branches of the facial artery, that is, glandular and/or facial branches and/or submental artery in various permutations. The upper jugular nodes were perfused by the sternocleidomastoid artery, which branches from the superior thyroid artery (70%) or emerges directly from the external carotid artery (30%). Hilar veins were found to drain into surrounding larger draining tributary veins and ultimately into the internal jugular vein. At 1-year follow-up, there was a considerable decrease in girth circumference in our patients, no episodes of cellulitis after surgery, with subjective improvement in limb heaviness and skin pliability. CONCLUSIONS: This knowledge of hilar blood supply will aid in transferring a lymphatic flap with intact microcirculation. When harvesting the submandibular nodes or upper jugular nodes, it is essential to harvest them based on their source pedicles, that is, facial artery and sternocleidomastoid artery, respectively, to supply live nodes to the recipient lymphedematous limb.

Short-term and long-term psychological impact and quality of life of patients undergoing orthognathic surgery.

BACKGROUND: Orthognathic Surgery (OGS) is a surgery for patients with dento-facial deformity but not all patients are satisfied with its outcome. The purpose of this study is to find out the short-term and long-term psychological impact and quality-of-life of OGS. METHODS: 77 participants receiving OGS and 32 age and gender-matched controls were enrolled. The data of questionnaires were collected before OGS, one month and 9 months after OGS, including short form of the Derriford-Appearance-Scale (DAS-24), Big-Five-Inventory (BFI), Hospital-Anxiety-and-Depression-Scale (HADS), Pittsburgh-sleep-quality-index (PSQI), and 36-Item Short-Form-Health-Survey (SF-36). Variables were presented as mean ± standard deviation or frequency. Paired t-test, ANOVA and MANOVA were used to evaluate the pre-and post-surgery data. RESULTS: Short-term and long-term satisfaction of OGS was high. Before OGS, BFI showed the extraversion had significant difference between the male and female OGS subgroups. Several domains of DAS-24 were significantly different between the OGS and the control groups. Both groups had no significant difference in PSQI, HADS and SF-36, except sleep-efficiency. After OGS, many domains of DAS-24 were significantly improved and the improvement persisted to 9 months later. Sleep-latency, physical-function, role-limitations-due-to-physical-health and social-functioning exacerbated after OGS. Sleep-latency, physical-function, and social-functioning were improved 9 months after OGS, but sleep-efficiency and role-limitations-due-to-physical-health were still significantly worse than controls. CONCLUSION: People received OGS for unfavorable appearance and the surgery could decrease their distress of appearance and impact to their daily living. Through long-term assessment, we should pay attention to sleep problems and role-limitations-due-to-physical-health after OGS.

The use of Urgotul in the treatment of partial thickness burns and split-thickness skin graft donor sites: a prospective control study.

The use of paraffin-impregnated gauze for burns and skin graft donor sites is commonly associated with wound adherence with consequent pain and trauma upon removal. This prospective clinical study was performed to evaluate a new class of lipido-colloid dressings (Urgotul) in promoting healing and in reducing tissue adherence. In a 6-month period, 25 consecutive patients were recruited. Two separate burn or donor sites on each patient were dressed with tulle-gras (TG) or Urgotul and covered with standard secondary dressings. Objective assessment of wounds by two reviewers, and patients' subjective assessments were recorded. Twenty-three (92%) patients were followed up for a mean of 3 months. Mean time to complete epithelialisation was 9.6 and 11.9 days for the Urgotul and TG sites respectively (P < 0.05). Bleeding was seen in 52% of Urgotul sites compared with 100% of the TG sites at first dressing change (P < 0.05). Patients reported 'moderate pain' during dressing change in 22% and 57% in the Urgotul and TG groups respectively (P < 0.05), with 35% of TG sites being 'very painful' requiring extra analgesia. We found that compared with TG, Urgotul was associated with faster epithelialisation, less pain and trauma (bleeding) during dressing changes.

Cultural perspectives in facial allotransplantation.

Facial allotransplantation is a clinical reality, proposed to provide improved functional and aesthetic outcomes to conventional methods of facial reconstruction. Multidisciplinary efforts are needed in addressing not just the surgical and immunological issues but the psychological and sociological aspects as well. In view of this, an international survey was designed and conducted to demonstrate that attitudes toward facial allotransplantation are highly influenced by cultural background. Of all countries surveyed, France had the highest percentage of respondents willing to donate their faces (59%) and Iraq had the lowest (19%). A higher percentage of respondents were willing to accepting a face transplant (68%) than donate their face after death (41%). Countries with a dominant Western population show greater percentages of willingness to accept a face transplant, as they exhibit more positive variables, that is, (1) acceptance of plastic surgery for disfigurement and for cosmetic reasons and (2) awareness to the world's first face transplant. Countries with a dominant Western population also show greater percentages of willingness to donate their faces after death, as they exhibit more positive variables, that is, (1) positive attitude to organ donation by being an organ donor themselves, (2) acceptance of plastic surgery if disfigured, and (3) awareness to the world's first face transplant. Although religion was sometimes cited as a reason for not donating their faces, data analysis has shown religion not to be a strong associating factor to willingness to donate a face after death.

Chest wall reconstruction using a combined musculocutaneous anterolateral-anteromedial thigh flap.

We present a massive 25 cm × 20 cm chest wall defect resulting from resection of recurrent cystosarcoma phyllodes of the breast along with six ribs exposing pleura. The chest wall was reconstructed with a Prolene mesh-methylmethacrylate cement sandwich while soft tissue reconstruction was carried out using a combined free anterolateral-anteromedial thigh musculocutaneous flap with two separate pedicles, anastomosed to the thoracodorsal and thoracoacromial vessels respectively. We explain our rationale for and the advantages of combining the musculocutaneous anterolateral thigh flap with the anteromedial-rectus femoris thigh flap.

Ehlers-Danlos syndrome associated with cleft lip and palate.

Ehlers-Danlos syndrome (EDS) is a hereditary connective tissue disorder caused by abnormal collagen synthesis and presents with classic features of hyperextensibility, fragility of skin and joint hypermobility. It has not been commonly described as being associated with cleft lip and/or palate, and a literature search has disclosed only one case (1984) of type IV EDS with cleft lip and palate. The authors have seen another case of EDS associated with cleft lip and palate. The etiology and clinical features of this syndrome are discussed alongside the clinical picture of cleft lip and palate.