Anatomical Location of Lymphatic Pathways in the Posterior Thigh.

BACKGROUND: It is necessary for treating lower extremity lymphedema to understand the lymphatic pathways in the extremities. This study aimed to clarify the anatomical locations of lymph vessels in the posterior thigh using indocyanine green (ICG) lymphography. METHODS: Medical records of cancer survivors who underwent ICG lymphography for secondary lymphedema screening from February 2019 to November 2020 were reviewed. Nonlymphedematous limbs without dermal backflow pattern on ICG lymphography (ICG stage 0) were included. Indocyanine green (0.1 mL) was injected intradermally at 2 points in the midlateral thigh, at the levels of one third and two thirds from the popliteal fossa to the gluteal fold in a prone position. Locations of the posterior thigh collecting lymph vessels visualized by ICG lymphography were marked on the skin surface with a pen, and distances from the popliteal fossa to the collecting lymph vessels were measured at the posterior midline in percentage, with the popliteal fossa set as 0% and the gluteal fold as 100%. Based on ICG lymphography findings, the number of the collecting lymph vessels shown as linear pattern and anatomical locations at the posterior thigh midline were investigated. RESULTS: Twenty limbs of 20 cancer survivors were included. Linear pattern was identified in all lower extremities; average number was 2.3 ± 0.7 (range, 1-3). Most collecting lymph vessels shown on ICG lymphography, 26.7% (12 of 45) lymph vessels, were located within 40% to 50% of the region, and 24.4% (11 of 45) lymph vessels within 30% to 40% of the region. CONCLUSIONS: There are 1 or more collecting lymph vessels in the posterior thigh by midlateral thigh ICG injection, which can be addressed for posterior thigh lymphedema.

Domino Free Flap Transfer Using a Superficial Circumflex Iliac Artery Perforator Flap for the Toe Flap Donor Site.

BACKGROUND: Toe-to-hand transfer is a favorable option for finger reconstruction, but donor site healing can be challenging. The superficial circumflex iliac artery perforator (SCIP) flap has yet to be used widely for toe reconstruction. The purpose of this report was to validate the efficacy of the sequential simultaneous free SCIP flap transfer for the toe flap donor site in a consecutive case series. METHODS: The medical records of 18 consecutive patients who underwent a simultaneous SCIP flap transfer and a toe-to-hand transplant were reviewed. Free SCIP flap reconstruction was performed in a simultaneous 2-team approach. The SCIP flaps were transferred to various toe flap donor sites: a great toe wraparound flap in 9 cases, a second toe distal phalangeal flap in 4 cases, a great toe osteo-onycho-cutaneous flap in 3 cases, a twisted wraparound flap in 1 case, and a great toe hemipulp flap in 1 case. RESULTS: The size of the SCIP flap ranged from 5 × 3 to 16 × 8 cm. A mean of the total operative time was 229.2 minutes (range, 118-441 minutes; SD, 75.8 minutes). All the SCIP and toe flaps survived completely. Minor wound dehiscence was seen in 2 cases, and the wound healed by conservative treatment. The mean follow-up period was 23.7 months (range, 7-44 months; SD, 9.7 months). No patient had gait dysfunction postoperatively. CONCLUSIONS: A sequential SCIP flap transfer was performed simultaneously without additional time, allowing secure soft tissue coverage of the toe flap donor even with avascular tissue such as bone or tendon exposed. The sequential SCIP flap transfer can be a useful option for reconstruction of toe flap donor site, when multiple microsurgeons and microscopes are available.

Thoracoacromial artery and vein as main recipient vessels in deep inferior epigastric artery perforator (DIEP) flap transfer for breast reconstruction.

BACKGROUND: The internal mammary artery/vein (IMA/V) are commonly used recipients for free flap breast reconstruction, but requires costal cartilage resection and limits future use of the IMA. This study aimed to evaluate the feasibility of the thoracoacromial artery/vein (TAA/V) as recipients for deep inferior epigastric artery perforator (DIEP) flap breast reconstruction compared with using the IMA/V. METHODS: Medical charts of patients who underwent free DIEP flap breast reconstruction using the TAA/V or the IMA/V as recipient vessels were reviewed. Patient and vessel characteristics, time for vessel preparation and anastomosis, and postoperative pain were compared between TAA/V and IMA/V groups. RESULTS: Thirty-four patients were included; 12 in TAA/V group, and 22 in IMA/V group. There was no flap failure in both groups. There were statistically significant differences between TAA/V and IMA/V groups in vessel preparation time (10.9 ± 3.7 min vs. 24.1 ± 6.0 min, p < .001), anastomosis time (31.2 ± 12.1 min vs. 42.1 ± 11.2 min, p = .017), and total dose of acetaminophen (4566.7 ± 1015.6 mg vs. 5436.4 ± 1323.3 mg, p = .041). CONCLUSIONS: The TAA/V could be safely used as recipient vessels for DIEP flap breast reconstruction with shorter time and less postoperative pain.

Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review.

Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.

Subacute Acrylamide Intoxication with Severe Visual Disturbance: A Case Report.

A 35-year-old man was admitted due to somnolence and progressive sensory-motor polyneuropathy, followed by severe visual impairment in both eyes after direct skin exposure to an acrylamide monomer solution. The results of an ophthalmological examination including central critical flicker fusion frequency and the decreased amplitude of action potentials observed in the visual evoked potential studies suggested that acrylamide intoxication resulted in neuronal degeneration in the optic pathways. Additional attention should be directed to the potential effect of acrylamide on the human visual system.

Three-dimensional non-contrast magnetic resonance lymphography severity stage for upper extremity lymphedema.

PURPOSES: Non-contrast magnetic resonance lymphography (NMRL) has recently shown the capability of evaluating anatomical fluid distribution in upper extremity lymphedema (UEL). However, there is still a lack of knowledge about the correlation between the characteristic three-dimensional (3D) NMRL findings and the indocyanine green lymphography (ICG-L) findings. Our goal was to clarify the relationship between the 3D NMRL findings and the ICG-L findings. METHODS: Medical charts of patients with secondary UEL who underwent NMRL and ICG-L between January 2018 to October 2021 were reviewed. The upper extremities were divided into 6 regions; the hand, elbow, and the radial and ulnar aspects of the forearm and the upper arm. We investigated the prevalence of characteristic 3D NMRL patterns (Mist/Spray/Inky) in each region based on the ICG-L stage. We also examined the association between the 3D NMRL stage which we proposed and the ICG-L stage, and other clinical factors. RESULTS: A total of 150 regions of 25 patients with upper extremities lymphedema were enrolled in the study. All of the characteristic patterns increased significantly as the ICG-L stage advanced (p < 0.001, < 0.001, and < 0.001, respectively). The predominant NMRL patterns changed significantly from the Early pattern (Mist pattern) to the Advanced pattern (Inky/Spray pattern) as the ICG-L stage progressed (p < 0.001). The higher Stage of 3D NMRL was significantly associated with the progression of the ICG-L stage (rs = 0.80, p < 0.001). CONCLUSIONS: Characteristic 3D NMRL patterns and the 3D NMRL Stage had a significant relationship with the ICG-L stage and other clinical parameters. This information may be an efficient tool for a more precise and objective evaluation of various treatments for UEL patients.

Progression of fluid infiltration on non-contrast magnetic resonance imaging in breast cancer-related lymphedema: A comparative analysis with indocyanine green lymphography.

BACKGROUND: Non-contrast magnetic resonance imaging (NMRI) has been reported as valuable for the assessment of lymphedema. However, the correlation between NMRI findings and indocyanine green lymphography (ICG-L) findings remains elusive. METHODS: This single-center retrospective study included 26 patients diagnosed with breast cancer-related lymphedema. We examined the prevalence of fluid infiltration in eight regions of the upper extremity, the type of fluid distribution, and the dominant segment of edema on NMRI in comparison to the ICG-L stage. Statistical analysis was performed using the Cochran-Armitage trend test, Spearman's rank correlation test, and Fisher's exact test. RESULTS: The regional fluid infiltration significantly increased with the progression of the ICG-L stage (hand, forearm, elbow, and upper arm: p = 0.003, <0.001, <0.001, and <0.001, respectively). The fluid distribution significantly advanced with the progression of the ICG-L stage as follows (rs = 0.80; p < 0.001): no edema in ICG-L stage 0, edema in either the hand or elbow in ICG-L stage I, edemas in both the elbow and hand in ICG-L stage II, three segmental edemas centered on the forearm or elbow in ICG-L stage III, and edema encompassing the entire upper limb in ICG-L stage IV-V. Additionally, the dominant segment of edema tended to shift from the hand to the elbow and further to the forearm as the ICG-L stage progressed (p < 0.001). CONCLUSIONS: Fluid infiltration observed on NMRI exhibited distinct patterns with the progression of the ICG-L stage. We believe that anatomical information regarding fluid distribution would potentially contribute to optimizing surgical efficacy.

Apparent involvement of plasmin in early-stage follicle rupture during ovulation in medaka.

Until recently, the role of the proteolytic system involving serine proteases in follicle rupture during ovulation in mammalian species has been a subject of controversy. We undertook the present study to examine whether proteases play a role in follicle rupture using the teleost medaka (Oryzias latipes) model. Various serine protease inhibitors, including a specific plasmin inhibitor, drastically reduced the rate of ovulation, as assessed by an in vitro ovulation assay, which was established for the fish. Biochemical, molecular biological, and immunological analyses demonstrated that plasminogen/plasmin was present in large follicles destined to ovulate. The active protease, plasmin, was detected in follicles approximately 3-7 h before the expected time of ovulation. Specific antibodies against the medaka plasmin light chain suppressed the ovulation rate of the follicles when antibodies were added to the medium during the period in which active plasmin was generated. This finding was an indication that a plasmin-like protease similar if not identical to plasmin plays a role in follicle rupture during ovulation in the medaka. Our data also indicate that this serine protease participates in the rupture for only a few hours prior to the activation of matrix metalloproteinase (Mmp)-mediated hydrolysis at ovulation. Based on our previous and current data, we propose a follicle rupture model involving two different proteolytic enzyme systems, serine protease and Mmp, in medaka ovulation. The current study is the first to provide evidence of the indispensable role of plasmin or a plasmin-like protease in the ovulation of a nonmammalian vertebrate species.