Successful Relief of a Male Breast Lymphedema by Supermicrosurgical Lymphaticovenular Anastomosis.

BACKGROUND: Breast lymphedema is a common issue after breast cancer surgery but remains understudied because it is difficult to be quantified. Untreated breast lymphedema may lead to severe form of delayed breast cellulitis. Supermicrosurgical lymphaticovenular anastomosis is one option for the treatment of breast cancer-related lymphedema but has not been described for the treatment of breast lymphedema. METHODS: This report presented a rare case of male breast lymphedema secondary to axillary lymph node dissection for the treatment of a forearm melanoma. Deep lymphatic vessels and adjacent venules were individualized under high magnification in the periareolar area. Six lymphaticovenular anastomoses were performed using supermicrosurgical techniques. A clinical examination and a volume assessment under magnetic resonance imaging were used to assess the efficiency of surgery. RESULTS: Postoperative outcome was uneventful. The patient was followed-up during 1 year. Swelling relief was clinically significant 3 months postoperatively. The pinch test reduction was 2 cm after 12 months. The breast volume reduction rate was 47.2%. CONCLUSIONS: Supermicrosurgical lymphaticovenular anastomosis may be efficient for the treatment of postoperative breast lymphedema, even in male patients.

A Comparative Study Between Deep Inferior Epigastric Artery Perforator and Thoracoacromial Venous Supercharged Deep Inferior Epigastric Artery Perforator Flaps.

BACKGROUND: Nowadays, microvascular breast reconstruction with abdominal perforator flap is a popular and widespread technique. However, venous congestion is a recurrent problem in deep inferior epigastric artery perforator (DIEP) flap survival. We present a venous supercharging technique using the thoracoacromial vein in DIEP free flap for breast reconstruction. METHODS: A prospective randomized study was conducted in 52 patients undergoing a free DIEP flap breast reconstruction. Classical DIEP flap using 1 venous anastomosis (DIEP group) was compared with thoracoacromial venous supercharged DIEP flap using the ipsilateral superficial epigastric vein as a supercharging vein (DIEP-TAsc group). The endpoint was to assess the equivalence or the superiority of each technique. Statistical analysis was made with the t test and the χ test. RESULTS: Venous congestion occurred in 16 (55.1%) patients in the DIEP group, and 3 (13%) patients in the DIEP-TAsc group (P = 0.001). The venous congestion rate was 36.5%. Fat necrosis was experienced by 14 (48.2%) patients in the DIEP group, and 4 (17.4%) patients in the DIEP-TAsc group (P = 0.020). The fat necrosis rate was 34.6%. Partial flap necrosis occurred in 13 (44.8%) patients in the DIEP group, and 2 (8.7%) patients in the DIEP-TAsc group (P = 0.004). The partial flap necrosis rate was 28.8%. Total flap necrosis occurred in 5 (17.2%) patients in the DIEP group, but no (0%) patient in the DIEP-TAsc group (P = 0.036). The total flap necrosis rate was 9.6%. The mean operative time was 405 minutes (range, 355-460) in the DIEP group, and 510 minutes (range, 405-590) in the DIEP-TAsc group (P < 0.001). CONCLUSIONS: Thoracoacromial venous supercharging using the ipsilateral superficial inferior epigastric vein is a valuable method which considerably secures the DIEP free flap in breast reconstruction although it lengthens the operative procedure. EBM level: Level III.

Reconstruction of post-traumatic drop foot deformity by the chimeric deep inferior epigastric artery perforator free flap associated with a composite quadriceps osteotendinous graft.

Dorsiflexor tendons are particularly exposed in crush injury of the foot. Anterior tibialis tendon defects may be responsible for a steppage gait and a drop foot deformity. Drop foot reconstruction is challenging because of the high risk of postoperative adhesions and functional sequelae. In this report, we present the results of the reconstruction of post-injury anterior tibialis tendon defects with chimeric deep inferior epigatric artery perforator (DIEP) free flap associated with a quadriceps osteotendinous graft in two patients. Two men (32-year-old and 19-year-old) presented drop foot deformity with defect of the anterior tibialis tendon secondary to a crush injury. The sizes of the soft tissues defects at the foot dorsum were 24 cm × 8 cm and 20 cm × 8 cm, respectively. The quadriceps osteotendinous grafts were used to reconstruct the anterior tibialis tendon in both patients. The chimeric DIEP free flaps with skin paddles (24 cm × 8 cm and 20 cm × 8 cm) and rectus abdominis fascia (24 cm × 4 cm and 20 cm × 4 cm) were used for reconstruction. The skin component based on a musculocutaneous perforator was used for soft tissue reconstruction of the foot dorsum. The fascial component based on a second perforator was used to create a sliding surface around the osteotendinous graft. Postoperative course was uneventful. Rehabilitation lasted 3 months. The range of ankle movement was measured during 12 months. The first patient recovered 10 degree of dorsiflexion. The second patient recovered 25 degree of dorsiflexion. Walk recovery was satisfying in both patients. The single-stage procedure using the chimeric DIEP free flap may be an option for post-injury drop foot reanimation. Creating a sliding surface around a composite osteotendinous quadriceps graft with a vascularized fascial component avoid postoperative peritendinous adhesions. This technique may improve foot dorsiflexion and walk recovery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:334-338, 2016.

Fluorescein sodium fluorescence microscope-integrated lymphangiography for lymphatic supermicrosurgery.

Microscope-integrated lymphangiography is a useful method in the field of lymphatic supermicrosurgery. Fluorescence based on indocyanine green (ICG) is the most commonly used. Fluorescein sodium is a fluorescent tracer used for retinal and neurosurgical angiography but not yet for lymphatic supermicrosurgery. In this report, we present a case in which the fluorescein sodium fluorescence microscope-integrated lymphangiography was used for assessment of lymphatic drainage pathway and patency in a patient treated for secondary lymphedema by lymphaticovenular anastomoses. Fluorescein sodium fluorescence microscope-integrated lymphangiography was evaluated in a 67-year-old female presented for a Campisi clinical stage IV lymphedema of the upper limb. Transcutaneous guidance and vascular fluorescence were assessed. A comparison with ICG fluorescence was made intraoperatively. Two lymphaticovenular anastomoses were performed and their patency were checked by lymphangiography. Transcutaneous signal was found higher with fluorescein sodium fluorescence. Intraluminal visualization was possible with fluorescein sodium coloration during lymphaticovenular anastomoses. No adverse reaction occurred. The circumferential differential reduction rate of affected limb was 8.1% 3 months after lymphaticovenular anastomoses. The use of fluorescence microscope-integrated lymphangiography with fluorescein sodium may be superior to ICG fluorescence in assistance of lymphaticovenular anastomoses.

Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap.

Gluteal artery perforator flaps are a good option to reconstruct perineal and posterior vaginal wall defects after abdominoperineal resection. The bulkiness of the folded flap may compromise the results by obliterating the introitus and vaginal cavity. In this report, we present a case of the use of a superior gluteal artery dual perforator-pedicled propeller flap to reconstruct the posterior vaginal wall and perineum in a 60-year-old female who had an abdominoperineal resection of a locally progressive anal squamous cell carcinoma. Two perforators were completely skeletonized through gluteus maximus muscle fibers. The vascularization of the skin flap was based on the first perforator, whereas the aponeurotic flap was vascularized by the second perforator. The vaginal defect was reconstructed with a gluteus maximus aponeurotic flap, and the perineal reconstruction was based on a superior gluteal artery perforator skin flap. No postoperative infection or necrosis occurred. Skin healing was completed in 3 weeks. Vaginal opening was controlled using lubricant and graduated vaginal dilators during 6 weeks. The patient began sexual intercourse 2 months postoperatively. No revision was needed. Perineal and posterior vaginal wall defects may be reconstructed with a gluteal artery perforator flap. The thickness of the flap allows a complete filling of the full perineal cavity. The gluteus maximus aponeurosis may be suitable for the reconstruction of the posterior vaginal wall.

π-shaped lymphaticovenular anastomosis: the venous flow sparing technique for the treatment of peripheral lymphedema.

BACKGROUND: Nowadays, lymphaticovenular anastomosis has been recognized as an efficient microsurgical treatment for peripheral lymphedema. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. This is the venous flow-sparing technique, in which the distal endothelial cells are not sacrificed. The purpose of this study is to evaluate the clinical results of π-shaped lymphaticovenular anastomosis in chronic lymphedema of the upper and lower limbs. PATIENTS AND METHODS: From November 2010 to August 2011, 20 patients with a peripheral lymphedema were treated by π-shaped lymphaticovenular anastomosis. A total of 12 patients had a lymphedema of the upper limb and 8 patients had a lymphedema of the lower limb. The mean age of the patients was 57.2 years (range, 44-78 years). The mean duration of lymphedema was 6.2 years (range, 1-23 years). The Campisi clinical stage range 2 to 5 (average, 3.3). Every patient was operated under local anesthesia. Four π-shaped lymphaticovenular anastomoses were performed per limb. RESULTS: The mean caliber of lymphatic vessels used for lymphaticovenular anastomosis was 0.55 mm (range, 0.3-0.8 mm). The mean caliber of subdermal venules was 1.2 mm (range, 0.5-2.1 mm).The average operative time to perform one π-shaped lymphaticovenular anastomosis was 55 minutes (range, 45-65 minutes). A venous backflow was found in 98 lymphaticovenular anastomosis (55.7%). Total 16 patients (80%) had a clinically significant circumferential reduction after surgery. The average volume differential reduction rate was 22.9% (range, 4.9-46.3) (p < 0.001). CONCLUSIONS: π-Shaped lymphaticovenular anastomosis is a supermicrosurgical method with a low morbidity to treat peripheral lymphedema. The procedure can easily be performed under local anesthesia, and the postoperative recovery is short. The results of this series demonstrate a clinical efficiency of the technique to reduce chronic lymphedema of the limbs.EBM level IV.

Small-wave plasty for correction of lip length deficiency: a case report.

BACKGROUND: Lip reconstruction may lead to disappointing results due to secondary deformity and visible scars. The Z-plasty in the Tennison technique is an effective method for repairing the upper lip subunits. The main issue is the visible and ungracious scar. METHODS: A 38-year-old woman was treated for an upper lip deformity secondary to a dog bite injury. At 1 month after a direct suture, a scar contracture with a defect of Cupid's bow and a vermilion height deficiency occurred. A Tennison procedure was chosen to repair the deformity. A small-wave incision procedure also was considered to minimize visibility of the scar. These two techniques were coupled in a small-wave plasty. The small-wave plasty design was performed with a superior flap base (L1) of 7 mm and a circle arc of 10 mm. The superior height (H1) was 3 mm. The middle flap base (L2) was 4 mm, and the circle arc was 6 mm. The middle height (H2) was 2 mm. RESULTS: The surgery time was 55 min with the patient under general anesthesia. The skin healing was completed in 10 days without scar contracture. The upper lip subunits were reconstructed with a regular Cupid's bow and a symmetric vermilion height. The scars were slightly visible at 1 month postoperatively. The results were stable after a follow-up period of 12 months. No revision was needed. CONCLUSION: The small-wave plasty, which couples a Tennison technique with a small-wave incision procedure, is efficient in reconstructing the subunits of the upper lip after a scar contracture deformity. This method should be used for upper lip reconstruction for minimal scar visibility. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vacuum-assisted adipose tissue suction technique (VAST) to optimize fat harvesting.

BACKGROUND: Nowadays, fat grafting is a widespread technique that is commonly used in plastic and reconstructive surgery. The classical fat-harvesting method in which a 10-cc syringe and a 3.0-mm cannula are used, may be time-consuming when a large quantity of adipose tissue is required. We describe a novel technique to optimize fat harvesting, the vacuum-assisted adipose tissue suction technique (VAST), in which disposable sterile components are used. This study compares the adipose tissue harvesting speed and the adipocyte volume between the VAST and the 10-cc-syringe technique. METHODS: From May 2010 to May 2012, a total of 32 patients who had structural fat grafting for breast reconstruction were enrolled in this prospective study. In 16 patients (control group) fat was harvested by the classical 10-cc-syringe technique, and in the other 16 patients (VAST group) fat was harvested by the VAST. Adipose tissue was harvested from the abdomen area in all patients. The volume of harvested adipose tissue was noted every minute during the operative procedure. The operative harvesting speed was calculated for each patient after 5 min. The volume harvested in 5 min was centrifuged, and the remaining adipocyte volume was noted after centrifugation. The operative harvesting speed and the remaining adipocyte rate were compared in both groups. RESULTS: The average volume of harvested adipose tissue was 18.1 ml in the control group and 156.2 ml in the VAST group (p < 0.001). The average harvesting speed was 3.6 ml/min in the control group using a 10-cc syringe and 31.2 ml/min in the VAST group (p < 0.001). The average remaining adipocyte volume, after centrifugation, was 13.5 ml in the control group, and 118.2 ml in the VAST group (p < 0.001). The average remaining adipocyte rate, after centrifugation, was 74.3 % in the control group and 75.4 % in the VAST group (p = 0.27). CONCLUSIONS: Adipose tissue harvesting can be optimized safely by using the VAST before structural fat grafting. Its quickness, low cost, and efficiency make us choose this method in breast reconstruction when a significant volume of adipocytes is required. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Vacuum-assisted retroauricular full-thickness skin grafting.

The authors describe a vacuum-assisted skin grafting method to optimize graft take in the retroauricular region. This method is demonstrated after skin tumor resection of the retroauricular and mastoid areas.

Galactorrhea after aesthetic breast augmentation with silicone implants: report of two cases and management of postoperative galactorrhea.

Galactorrhea is a rare event after breast augmentation. The physiopathologic bases of galactorrhea depend on the central secretion of prolactin. These physiopathologic bases must be clearly understood for the prevention and treatment of postoperative galactorrhea. This report describes two cases of a postoperative galactorrhea after aesthetic breast augmentation with silicone implants. The clinical appearance closely resembles a postoperative sepsis without hyperthermia. Bacteriologic samples are negative. Endocrinologic examination finds a characteristic hyperprolactinemia. The evolution is favorable under dopaminergic agonists.

End-to-side versus end-to-end neurorrhaphy at the peroneal nerve in rats.

PURPOSE: To evaluate three different kinds of neurorrhaphy of the peroneal nerve. METHODS: Eigthy rats were divided into 5 groups. Control: nerve had no intervention. End-to-end (EE): nerve was cut and elongated with a nerve graft with two end-to-end neurorrhaphies. End-to-side (ES): nerve was cut and sutured to the graft with at the lateral side of the nerve. Side-to-end (SE): the nerve was cut and sutured to the graft with end-to-end neurorrhaphy. Denervated: nerve was cut and both endings were buried into the muscle. The evaluation was done by walking track analysis, electrophysiology, body mass, cranial tibial muscle mass, nerve and muscle fibers morphometry. RESULTS: The EE, ES and SE have the same potential of reinnervation. CONCLUSION: There is no functional or histological difference between these different types of neurorrhaphy.

A Systematic Review and Meta-Analysis of Perforator-Pedicled Propeller Flaps in Lower Extremity Defects: Identification of Risk Factors for Complications.

BACKGROUND: Currently, increased interest in the perforator-pedicled propeller flap should not obscure the fact that it is, in reality, a complex procedure requiring experience and monitoring similar to free flaps. Through a meta-analysis, the authors aimed to identify the risk factors of perforator-pedicled propeller flap failure in lower extremity defects. METHODS: The MEDLINE, PubMed Central, Embase, and Cochrane databases were searched from 1991 to May of 2014 for articles describing perforator-pedicled propeller flaps in the lower extremity. The study selection met the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Fixed-effects models were used. RESULTS: Forty articles complied with the inclusion criteria, representing 428 perforator-pedicled propeller flaps. The most common cause was posttraumatic (55.2 percent). Most of the defects were at the distal third of the lower leg (45.6 percent). The arc of rotation was 180 degrees for 34.3 percent. Complications were found in 25.2 percent, including partial necrosis (10.2 percent) and complete necrosis (3.5 percent). Complete flap survival was found in 84.3 percent. The authors identified three significant risk factors: age older than 60 years (relative risk, 1.61; p = 0.03), diabetes (relative risk, 2.00; p = 0.02), and arteriopathy (relative risk, 3.12; p = 0.01). No significant results were found regarding smoking status other than a tendency (p = 0.06), acute cause (p = 0.59), posttraumatic cause (p = 0.97), distal third of the lower leg (p = 0.66), fascia inclusion (p = 0.70), and pedicle rotation greater than 120 degrees (p = 0.41). CONCLUSION: Age older than 60 years, diabetes, and arteriopathy are significant risk factors of perforator-pedicled propeller flap complications in the lower extremity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

π-shaped lymphaticovenular anastomosis for head and neck lymphoedema: a preliminary study.

BACKGROUND: Head and neck lymphoedema secondary to jugular lymphadenectomy is a severe issue, without efficient solution. Successful treatment of lymphoedema of the upper and lower limbs has become possible with supermicrosurgical lymphaticovenular anastomosis. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. We have evaluated this method for chronic head and neck lymphoedema. METHODS: From November 2010 to April 2011, four patients with a chronic head and neck lymphoedema were treated by π-shaped lymphaticovenular anastomosis. Three patients had a unilateral lymphoedema, and one patient had a bilateral lymphoedema. The mean age of the patients was 63.2 years (range, 46-77 years). The mean duration of the lymphoedema was 2.6 years (range, 1-5). Every patient was operated under local anaesthesia through a face-lift skin incision. One π-shaped lymphaticovenular anastomosis was performed at each operative site. RESULTS: The average operative time to perform one π-shaped lymphaticovenular anastomosis was 1.9 h (range, 1.8-2.5). The calibre of lymphatic vessels used for lymphaticovenular anastomosis ranged from 0.3 to 0.7 mm (average, 0.5). A venous back-flow was found in seven lymphaticovenular anastomosis (70%). Three patients (75%) had a qualitative improvement of skin tissue and a significant circumferential reduction after surgery. The average circumferential differential reduction rate was 3.7% (range, 0.6-7.8) (p=0.006). The average cross-sectional area differential reduction rate was 7.2% (range, 1.2-15.1) (p=0.007). The average volume differential reduction rate was 6.9% (range, 2-14.8) (p=0.05). CONCLUSIONS: The authors present a new option to treat head and neck lymphoedema. π-Shaped lymphaticovenular anastomosis is an effective method to reduce the severity of skin tissue fibrosis and lymphoedema volume. Further studies with larger groups of patients are required to confirm the outcome of this preliminary study. EBM Level=level 4.

Patent blue-enhanced lymphaticovenular anastomosis.

BACKGROUND: Lymphoedema supermicrosurgery is known to be difficult to perform. Lymphatic vessels are not easy to individualise, because of their small calibre (inferior to 1 mm) and their translucent appearance. Patent blue is an organic colourant, which is able to enhance the lymphatic network. We have evaluated the morbidity and the efficacy of patent blue lymphatic enhancement, with a view to perform lymphaticovenular anastomosis. METHODS: From November 2010 to January 2012, 20 patients with chronic lymphoedema of the upper limb were treated by lymphaticovenular anastomosis. The mean age of the patients was 60.1 years (range, 47-78 years). The mean duration of lymphoedema was 3.2 years (range, 1-9 years). The mean volume of patent blue injected subdermally before surgery was 1.3 ml (range, 1-2 ml). The number and the calibre of enhanced lymphatic vessels at each operative site were noted. The quality of patent blue enhancement was analysed. The efficacy of surgery was assessed by quantitative measures. RESULTS: The mean number of coloured lymphatic vessels per operative site was 2.1 (range, 1-4). The calibre of lymphatic vessels ranged from 0.3 to 0.8 mm (average, 0.57 mm). The quality of enhancement was moderate in two patients (8%), good in nine patients (36%) and excellent in 14 patients (56%). The mean number of lymphaticovenular anastomosis performed per operative site was 2.8 (range, 2-4). The mean operative time was 2.3 h (range, 2-3 h). No allergic (0%) and infectious (0%) reactions secondary to patent blue injection occurred. No secondary lymphangitis (0%) was noted. The delay of skin resorption of the blue stain ranges from 20 to 45 days (average, 30.3 days). Four patients (20%) had a remaining blue staining at the injection site. The average circumferential differential reduction rate was 13.2% (range, 4.2-27.2%) (p<0.001). The average cross-sectional area differential reduction rate was 24.1% (range, 9.5-46.7%) (p<0.001). The average volume differential reduction rate was 22.8% (range, 7.2-48.8%) (p<0.001). CONCLUSIONS: Patent blue-enhanced lymphaticovenular anastomosis is a safe and effective technique to treat patients with secondary lymphoedema. Its ease of use, low cost and efficiency should make it used on a priority basis to perform lymphaticovenular anastomosis.

End-to-side versus end-to-end neurorrhaphy at the peroneal nerve in rats

Abstract Purpose: To evaluate three different kinds of neurorrhaphy of the peroneal nerve. Methods: Eigthy rats were divided into 5 groups. Control: nerve had no intervention. End-to-end (EE): nerve was cut and elongated with a nerve graft with two end-to-end neurorrhaphies. End-to-side (ES): nerve was cut and sutured to the graft with at the lateral side of the nerve. Side-to-end (SE): the nerve was cut and sutured to the graft with end-to-end neurorrhaphy. Denervated: nerve was cut and both endings were buried into the muscle. The evaluation was done by walking track analysis, electrophysiology, body mass, cranial tibial muscle mass, nerve and muscle fibers morphometry. Results: The EE, ES and SE have the same potential of reinnervation. Conclusion: There is no functional or histological difference between these different types of neurorrhaphy.