Evaluation of the Superficial Collecting Lymph Vessels' Vasa Vasorum in Lymphoedematous Limbs Using Video Capillaroscopy.

OBJECTIVE: The pre-collecting and collecting lymph vessels have smooth muscle cells, and sufficient perfusion is vital to maintain their function. Although the vasa vasorum of the collecting lymph vessels (VVCL) have been histologically investigated, little is known about their physiology. This study aimed to investigate the relationship between morphology and blood flow of the VVCL in lymphoedematous limbs. METHODS: Medical records of lower extremity lymphoedema patients who underwent video capillaroscopy observation during supermicrosurgical lymphaticovenous anastomosis (LVA) surgery were reviewed. The collecting lymph vessels, dissected for LVA, were examined under video capillaroscopy (GOKO Bscan-ZD, GOKO Imaging Devices Co., Japan) with a magnification of 175x and 620x. Blood flow velocity of the VVCL was calculated by measuring the red blood cell movement using software (GOKO-VIP ver. 1.0.0.4, GOKO Imaging Devices Co., Japan). Based on the video capillaroscopy findings, the VVCL were grouped according to their morphology; the VVCL morphology types and blood flow velocity were then compared according to the lymphosclerosis severity grade. RESULTS: Sixty-seven lymph vessels in 20 lower extremity lymphoedema patients were evaluated, including s0 in 19 (28.4%), s1 in 34 (50.7%), s2 in 10 (14.9%), and s3 in four (6.0%) lymph vessels. The VVCLs were grouped into four types: type 1 (n = 4), type 2 (n = 37), type 3 (n = 19), and type 4 (n = 7). Blood flow velocity of the VVCL ranged 0 - 189.3 µm/sec (average 26.40 µm/sec). There were statistically significant differences in VVCL morphology (p < .001) and blood flow velocity (p < .001) according to lymphosclerotic severity. CONCLUSION: Vasa vasorum of the collecting lymph vessels could be grouped into four types with different characteristics. Morphological and physiological changes of the VVCL were related to sclerotic changes of the collecting lymph vessels.

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.

Sensate superior gluteal artery perforator flap for reconstruction of sacrococcygeal large wound dehiscence: A case report and literature review.

The superior gluteal artery perforator (SGAP) flap is an option for the reconstruction of deep sacral defects. Since a conventional SGAP flap is not neurotized, covered ulcers have a risk of recurrence, especially when patients cannot ambulate by themselves. In ambulatory patients, the sensory presentation of reconstructed tissue assures its protection. Purpose of this report is to present a case of the use of a sensate SGAP flap for reconstruction of a sacrococcygeal large wound dehiscence in a patient and review of literature for sensate reconstruction of sacral defects. A 72-year old woman with a sacrococcygeal large wound dehiscence measuring 12 cm in length, 9.5 cm in width and 5 cm in depth was treated. The defect was caused by a wound dehiscence after abdomino-perineal resection for rectal cancer. A unilateral SGAP flap measuring 16 × 7 cm length and 5 cm width was designed in the right buttock and the cranial border of the flap was lined near the iliac crest. An SGAP flap was elevated including the superior cluneal nerve (SCN), turned clockwise 70°, and inset to the defect. The defect remained in the deep caudal part a parasacral adiposal flap measuring 7 × 10 cm was harvested from the contralateral side and filled the defect. The postoperative course was uneventful without any complication. Sensation was observed immediately after surgery. Postoperative Semmes-Weinstein monofilament test showed 3.22 at 9 months postoperatively. There was no recurrence during follow-up of 20 months. The sensate SGAP flap may be elevated with SCN and be considered for reconstructions of deep sacral defect.

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 medialis tarsus flap transfer for reconstruction of toe necrosis: A case report.

The medial tarsal area is a commonly used donor site for skin grafts to the digits and toes, with good color and texture match as well as a concealable donor site scar. Yet, there has been no report as a perforator free flap donor site. The purpose of this report is to present a new perforator flap harvested from medial tarsal region. We present a case of a soft tissue defect of the fifth toe due to essential thrombocythemia (ET), successfully treated with a free medialis tarsus flap (MTF) transfer. A 62-year-old male with ET suffered from the right fifth toe necrosis caused by digital artery thrombosis. After the manifestation of the necrosis, necrotic tissue was completely debrided, which resulted in a 3 × 1.5 cm skin defect with exposure of the tendon and the phalangeal bone. Sixth days after debridement, a 4.5 × 1.7 cm MTF was harvested transversely and inferiorly to the right medial ankle, locating the preoperatively detected posterior tibial artery perforator (PTAP) in the flap. Perforator-to-perforator anastomosis was done using the dorsal metatarsal artery perforator and the subcutaneous vein as recipient vessels. The donor site was closed primarily. Postoperative course was uneventful, and the reconstruction preserved the toe length and functions of extension and flexion at 9 months postoperatively. The patient could walk with conventional shoes by himself. MTF may be an option for small skin defect in the digits and toes where skin graft is not indicated.

Free superficial circumflex iliac artery perforator fascial flap for reconstruction of upper abdominal wall with extensive infected herniation: A case report.

Complex abdominal wall reconstruction is challenging, and vascularized fascia is preferred for active infection cases. Pedicled tensor fascia lata flap is commonly used for lower abdominal wall reconstruction, and free vascularized fascial flap based on the lateral circumflex femoral artery (LCFA) is used for upper abdominal wall reconstruction. However, LCFA-based flap transfer requires invasive and time-consuming muscle dissection and a large recipient vessel. The purpose of this report was to present a new application of superficial circumflex iliac artery (SCIA) perforator (SCIP)-based fascial flap for upper abdominal wall reconstruction. A 70-year-old male suffered from a long-lasting extensive abdominal wall herniation complicated with mesh infection and cutaneous fistulae following multiple herniation repair with synthetic mesh. After complete debridement of infected tissues, there was a 29 x 26 cm full-thickness abdominal wall defect. Components separation was performed to minimize the defect size, after which 12 x 7 cm defect remained in the upper abdominal wall. A 20 x 10 cm SCIP deep fascial flap was elevated based on the deep branch of the SCIA. The SCIP flap was transferred to the defect to reconstruct the upper abdominal wall. The SCIP was anastomosed to the deep inferior epigastric artery perforator with supermicrosurgical perforator-to-perforator anastomosis. Postoperative course was uneventful with good functional and esthetic results of the donor and recipient sites 11 months after the surgery. Although further studies are required, SCIP fascial flap may be an option for upper abdominal wall reconstruction.

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.

Transversely-inset great toe hemi-pulp flap transfer for the reconstruction of a thumb-tip defect.

Thumb-tip defect is a common traumatic disease, and replantation of an amputated thumb-tip is the first choice of treatment when available. When an amputee is not available, local flaps such as volar advancement flap are used for reconstruction. However, it is difficult to cover whole defect area by a local flap when a defect is relatively large. In this report, we present a case of the use of a free great toe hemi-pulp flap transfer to reconstruct a thumb-tip defect. A 69-year-old right-handed male suffered from the right thumb-tip crush amputation in Tamai Zone 2. The distal phalanx and the nail matrix were preserved, and the defect size was 5 cm × 4 cm. The thumb-tip was reconstructed with a free great toe hemi-pulp flap under local anesthesia. The flap included extended subcutaneous adiposal tissue (skin size 4.5 cm × 3 cm; fat size 4.5 cm × 5.5 cm) to reconstruct the nail bed, and was transversely inset at the recipient site to cover the whole area of the defect. The donor site could be primarily closed without skin grafting. At postoperative 6 months, the patient was satisfied with good results of the reconstructed thumb-tip and the donor site. Transversely-inset great toe hemi-pulp flap may be useful to reconstruct a thumb-tip defect, which allows relatively wide defect reconstruction.

Characteristic Single Photon Emission Computed Tomography-Computed Tomography Findings in Lower Extremity Lymphedema: Comparison to Indocyanine Green Lymphography.

Introduction: Evaluation of lymph circulation is significant in lower extremity lymphedema (LEL) management. Single-photon emission computed tomography-computed tomography (SPECT-CT) has been introduced for lymphedema evaluation, but its characteristic findings are yet fully clarified. The purpose of this study was to reveal typical SPECT-CT findings in secondary LEL by contrasting with indocyanine green (ICG) lymphography findings. Methods: This is a single-center retrospective case-control study. Medical charts of cancer survivors who underwent SPECT-CT and ICG lymphography for secondary LEL were reviewed. Lymphedematous limbs were defined as ICG lymphography stage I-V and non-lymphedematous limbs were defined as ICG lymphography stage 0. Characteristic SPECT-CT findings were identified in early phase and delay phase, and prevalence of the findings was compared between lymphedematous limbs and non-lymphedematous limbs. Results: Thirty-four limbs of 17 patients were included in this study; 6 (17.6%) non-lymphedematous limbs and 28 (82.4%) lymphedematous limbs. Four characteristic SPECT-CT findings were identified; delayed enhancement of the main lower leg lymphatic pathway (DML), few delayed inguinal lymph nodes enhancement (FDN), early phase discontinuous enhancement of the main lymphatic pathway (EDM), and nonenhancement of the deep lymphatic pathways in early phase (NDE). Between lymphedematous and non-lymphedematous limbs, there were statistically significant differences in FDN (64.3% vs. 0%, p = 0.004) and EDM (67.9% vs. 0%, p = 0.002). Conclusions: FDN and EDM are characteristic SPECT-CT findings in secondary LEL.

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.

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.