Free prepuce perforator flap: Ultra-thin superficial penile artery perforator flap for a dorsal finger defect.

Dorsal skin defect of the hand/digit requires thin and pliable skin for coverage. The prepuce skin, the second thinnest skin, can be a reconstructive option, but there is no previous report of a free prepuce flap for the reconstruction of the hand/digit. We report the first successful case of a free prepuce flap based on the superficial penile artery perforator (SPAP) for the treatment of dorsal soft tissue defect of the hand/digit. A 68-year-old male presented with a 5 x 3 cm dorsal soft tissue defect of the left index finger with the extensor tendon exposure. A prepuce perforator flap was raised based on the SPAP. The flap was transferred to the recipient site, and the SPAP was supermicrosurgically anastomosed to the dorsal branch of the digital artery. The patient complained no postoperative discomfort of the donor penis, and was satisfied with functionally pleasing and esthetically acceptable results of the reconstructed finger and the donor site. Although only applicable for male patients without past history of penile trauma such as circumcision, a prepuce perforator flap may be an option for thin and pliable skin reconstruction with minimal donor site morbidity. © 2016 Wiley Periodicals, Inc. Microsurgery 37:252-255, 2017.

Lymphadiposal Flaps and Lymphaticovenular Anastomoses for Severe Leg Edema: Functional Reconstruction for Lymph Drainage System.

BACKGROUND: Collecting lymphatics have lymph-drainage function with contraction of smooth muscle cells. Patients with edema have lost this drainage function due to degeneration of smooth muscle cells. Lymphaticovenular (LV) anastomosis salvages smooth muscle cells from reversible degeneration (mild edema), but muscle cells cannot be recovered from irreversible degeneration (severe edema). Therefore, in severe edema, LV anastomoses cannot reestablish the drainage function of the lymphatic system.To overcome this weakness of LV bypass methods for severe edema, new methods were instituted for repair of this missing drainage function using a lymphadiposal flap from the contralateral foot for hemilateral edema, or transfer of lateral thoracic lymph nodes for bilateral edema. METHODS: A total of 13 cases were repaired with lymphadiposal flaps and additional LV anastomoses. These cases have frequent phlegmon or cellulitis or resisted to previous LV anastomoses and/or compression therapy. The ages ranged from 15 to 75 years. There were four cases of primary edema and nine cases of secondary edema. RESULTS: Regarding the lymphadiposal flap (n = 8), three cases showed an excellent response (37.5%; no need for compression therapy), four cases had a good response (50%; improvement with compression), one case showed no change (12.5%; no improvement), and there were no cases of deterioration. Regarding the lateral thoracic lymph nodes transfer (n = 5), two cases had a good response (40%), three showed no improvement (60%), and there were no cases of deterioration. CONCLUSION: It is concluded that lymphadiposal flap or lymph nodes transfer is suitable for severe edema having frequent cellulitis in unilateral or bilateral lower extremities resisting previous LV anastomoses and/or compression therapy.

Dynamic Indocyanine Green (ICG) lymphography for breast cancer-related arm lymphedema.

BACKGROUND: Lymph transportation capacity is a critical function maintaining fluid circulation. After breast cancer treatments, lymph obstruction at the axilla leads to abnormal lymph circulation, resulting in lymph pump dysfunction. As well as lymph circulation, lymph pump function is important for lymphedema evaluation. METHODS: We assessed and analyzed lymph transportation capacity of 15 breast cancer-related arm lymphedema patients using dynamic indocyanine green (ICG) lymphography. RESULTS: ICG velocity and transit time could evaluate lymph pump function; ICG velocity decreases and transit time increases as the lymphedema severity stage progresses. Measurement of ICG velocity required 3 minutes after the dye injection, whereas that of transit time took more than 1 hour in severe cases. CONCLUSIONS: ICG velocity can be easily obtained and is recommended for evaluation of lymph pump function. Dynamic ICG lymphography, which evaluates both lymph pump function and circulation, plays an important role in comprehensive assessment of lymphedema pathophysiology.

Sequential anastomosis for lymphatic supermicrosurgery: multiple lymphaticovenular anastomoses on 1 venule.

BACKGROUND: Supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a treatment option for progressive lymphedema. Various types of LVA such as end-to-end, end-to-side, side-to-end, and side-to-side are performed to improve the treatment efficacy. METHODS: We applied sequential anastomosis for LVA surgery, in which 2 lymphatic vessels were anastomosed to 1 venule using side-to-side and side-to-end anastomoses. Six lower extremity lymphedema (LEL) patients who underwent sequential anastomosis were included in this study. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. RESULTS: Six sequential anastomoses were performed on 6 lymphedematous limbs. All sequential anastomoses showed good anastomosis patency after completion of anastomoses. A significant decrease in LEL index was seen postoperatively (244.0 ± 14.6; postoperative LEL index vs 263.5 ± 19.4; preoperative LEL index, P = 0.002). CONCLUSIONS: Sequential anastomosis can divert both normograde and retrograde lymph flows from 2 lymphatic vessels into 1 venule. Sequential LVA is a useful method to increase lymph flow bypasses, when there are fewer venules than lymphatic vessels.

Predictive lymphatic mapping: a method for mapping lymphatic channels in patients with advanced unilateral lymphedema using indocyanine green lymphography.

In severe lymphedema, indocyanine green lymphography cannot be used to map lymphatic channels before lymphaticovenular anastomosis (LVA) because linear lymphatics cannot be detected in a severely affected leg. Here, we describe a new method, which we refer to as predictive lymphatic mapping, to predict the location of lymphatics for anastomosis in unilateral lymphedema, thereby improving surgical accuracy and efficiency. The approach consists of marking anatomical landmarks and joining selected landmarks with fixed lines. The distance from these fixed lines to lymphatic channels mapped by indocyanine green lymphography in the unaffected leg is then measured, scaled up based on the difference in circumference between the legs, and transposed to the affected leg. To date, we have used this method in 5 cases of unilateral or asymmetric lymphedema of the lower extremities. In no cases have we failed to find a lymphatic channel suitable for LVA within a 2-cm incision. These results suggest that predictive lymphatic mapping is a useful additional tool for surgeons performing LVA under local anesthesia, which will help to improve the accuracy of incisions and the efficiency of surgery.

Ladder-shaped lymphaticovenular anastomosis using multiple side-to-side lymphatic anastomoses for a leg lymphedema patient.

Lymphatic supermicrosurgery, supermicrosurgical lymphaticovenular anastomosis (LVA), is becoming a useful option for the treatment of compression-refractory lymphedema. One of the most important points in LVA is to make as many bypasses as possible for better treatment results. We report a progressive lower extremity lymphedema (LEL) case successfully treated with a ladder-shaped LVA. A 67-year-old female with secondary LEL refractory to conservative treatments underwent LVA. A ladder-shaped LVA was performed at the left ankle. In the ladder-shaped LVA, 3 lymphatic vessels and 1 vein were anastomosed in a side-to-side fashion; 2 lymphatic vessels next to the vein were anastomosed to the vein, and the other lymphatic vessel was anastomosed to the nearby lymphatic vessel. Using ladder-shaped LVA, 6 lymph flows of 3 lymphatic vessels could be bypassed into a vein. Six months after the LVA operation, her left LEL index decreased from 212 to 195, indicating edematous volume reduction. Ladder-shaped LVA may be a useful option when there are 3 lymphatic vessels and 1 vein in a surgical field.

Use of non-enhanced angiography to assist the second toetip flap transfer for reconstruction of the fingertip defect.

Toetip flap transfer is a useful reconstructive method for fingertip defect, but elevation of a toetip flap is technically demanding because of difficulty to dissect a pedicle vein of the flap. Recently, nonenhanced angiography (NEA) has been reported to be useful for preoperative visualization of the digital vessels without contrast enhancement or invasiveness. We report a case in which preoperative NEA visualized a vein suitable for a venous pedicle of a second toetip flap and facilitated successful toetip flap transfer for reconstruction of a fingertip defect. A 27-year-old male suffered from the right middle fingertip crush amputation in Tamai zone 1. The fingertip was reconstructed using a second toetip flap with preoperative NEA guidance. A pedicle vein was easily found and dissected exactly where NEA visualized. Nine months after the toetip flap transfer, the reconstructed right middle finger was functionally and aesthetically pleasing, and the toe nail at the donor site was preserved without any morbidity. NEA may help a surgeon to find drainage veins for a toetip flap, which leads to easier and more secure toetip flap transfer.

Effective treatment of pelvic lymphocele by lymphaticovenular anastomosis.

OBJECTIVE: Pelvic lymphocele can be a severe complication associated with surgical procedures such as pelvic lymphadenectomy. Lymphaticovenular anastomosis (LVA) is increasing in popularity as a surgical treatment for lymphedema. The aim of this study was to evaluate whether LVA is an effective treatment for lymphocele, which is caused by an obstruction of the lymphatic flow in a manner similar to the development of lymphedema. METHODS: Eleven female patients, who presented with lymphocele, were treated with LVA. Before the operation, 3 of them were treated with a percutaneous catheter. Lymphocele size and the volume of daily drainage were measured before and after LVA. RESULTS: The lymphocele was completely resolved in 6 patients and partially resolved in the remaining 5 patients. The mean size of the pelvic lymphocele changed from 400 ml (range 50-1050 ml) to 43 ml (range 0-120 ml) (P<0.01). In the 3 patients who had percutaneous drainage catheters, the volume of fluid drained decreased from 340 ml/day to 20 ml/day after LVA. CONCLUSIONS: Our technique is minimally invasive and is performed under local anesthesia. LVA is effective regardless of the size of the lymphocele. Therefore, LVA should be considered as a therapy for lymphocele because of its low invasiveness and its effectiveness in re-establishing circulation of lymphatic flow. Further studies should be performed to compare LVA with other minimally invasive techniques, such as percutaneous catheter and sclerotherapy.

Single-photon emission computed tomography (SPECT) predicted neurological prognosis in heat stroke: A case report.

Heat stroke may cause multi-organ dysfunction and death. Some patients with neurological abnormalities in the acute phase have neurological sequelae, particularly cerebellar ataxia, in the recovery phase. However, there is no method to predict the neurological prognosis, and the usefulness of imaging has not yet been established. We report the case of an 86-year-old woman with dementia brought to our emergency department in a coma and hyperthermia. The patient was diagnosed with heat stroke and promptly treated in the ICU but remained unconscious. The patient gained consciousness on day 19, but difficulty with stillness associated with cerebellar ataxia in her right upper extremity became apparent. On day 1, head magnetic resonance imaging (MRI) showed no obvious abnormality. However, on day 6, high-signal areas, suggestive of edema, were seen in the bilateral cerebellar hemispheres. Single-photon emission computed tomography (SPECT) on day 9 revealed significant hypoperfusion in the right cerebellum. These changes improved at the time of hospital discharge. This was a case of persistent cerebellar ataxia due to heat stroke, in which imaging findings improved over time. In most cases, MRI findings do not match clinical symptoms. However, the low cerebral blood flow in the early SPECT images was consistent with the clinical symptoms. MRI may not be a prognostic indicator; however, SPECT images may be useful for predicting sequelae.

Sedation Therapy in Intensive Care Units: Harnessing the Power of Antioxidants to Combat Oxidative Stress.

In critically ill patients requiring intensive care, increased oxidative stress plays an important role in pathogenesis. Sedatives are widely used for sedation in many of these patients. Some sedatives are known antioxidants. However, no studies have evaluated the direct scavenging activity of various sedative agents on different free radicals. This study aimed to determine whether common sedatives (propofol, thiopental, and dexmedetomidine (DEX)) have direct free radical scavenging activity against various free radicals using in vitro electron spin resonance. Superoxide, hydroxyl radical, singlet oxygen, and nitric oxide (NO) direct scavenging activities were measured. All sedatives scavenged different types of free radicals. DEX, a new sedative, also scavenged hydroxyl radicals. Thiopental scavenged all types of free radicals, including NO, whereas propofol did not scavenge superoxide radicals. In this retrospective analysis, we observed changes in oxidative antioxidant markers following the administration of thiopental in patients with severe head trauma. We identified the direct radical-scavenging activity of various sedatives used in clinical settings. Furthermore, we reported a representative case of traumatic brain injury wherein thiopental administration dramatically affected oxidative-stress-related biomarkers. This study suggests that, in the future, sedatives containing thiopental may be redeveloped as an antioxidant therapy through further clinical research.

Myotube orientation using strong static magnetic fields.

In this experiment, we evaluated the effects of strong static magnetic fields (SMF) on the orientation of myotubes formed from a mouse-derived myoblast cell line, C2C12. Myogenic differentiation of C2C12 cells was conducted under exposure to SMF at a magnetic flux density of 0-10 T and a magnetic gradient of 0-41.7 T/m. Exposure to SMF at 10 T led to significant formation of oriented myotubes. Under the high magnetic field gradient and a high value of the product of the magnetic flux density and magnetic field gradient, myotube orientation increased as the myogenic differentiation period increased. At the 3 T exposure position, where there was a moderate magnetic flux density and moderate magnetic field gradient, myotube orientation was not observed. We demonstrated that SMF induced the formation of oriented myotubes depending on the magnetic flux density, and that a high magnetic field gradient and a high value of the product of the magnetic flux density and magnetic field gradient induced the formation of oriented myotubes 6 days after myogenic differentiation. We did not detect any effect of the static magnetic fields on myogenic differentiation or cell number. To the best of our knowledge, this is the first report to demonstrate that myotubes orient to each other under a SMF without affecting the cell number and myogenic differentiation.

Lower limb lymphedema treated with lymphatico-venous anastomosis based on pre- and intraoperative icg lymphography and non-contact vein visualization: A case report.

Lymphatico-venous anastomosis (LVA) is used to resolve lymph retention in lymphedema. However, the postoperative outcome of lower limb lymphedema is poorer than that for upper limb lymphedema, because of the location lower than the heart level. Improvement of the therapeutic outcome requires application of as many anastomoses as possible in a limited operation time, particularly since there is a positive correlation between the number of anastomoses and the therapeutic effect of LVA. In this case, we described a method to increase the efficiency of lymphatico-venous anastomosis for bilateral severe lower limb lymphedema through efficient identification of lymph vessels and veins suitable for anastomosis using indocyanine green (ICG) contrast imaging and AccuVein, a noncontact vein visualization system, respectively. Ten LVAs were succeeded at seven incisions, and the operation time was 3 hours and 5 minutes. Accuvein can be used for identification of subcutaneous venules with a diameter of about 0.5-1.0 mm. We used this approach in surgery for a case of bilateral lower limb lymphedema, with a resultant improvement in the surgical outcome.

Intravascular stenting (IVaS) method for fingertip replantation.

Remarkable progress has been made in microsurgery. However, fingertip replantation following amputation has not gained much popularity because of its technical difficulty. We have developed the intravascular stenting (IVaS) method, in which a nylon monofilament is placed inside the vessel lumen to act as a temporary stent, facilitating anastomosis completion. This report describes 7 fingertip replantations using the IVaS method. Intravascular stent size varied from 4-0 to 6-0 (0.199-0.07 mm diameter). There were no cases in which the back wall of a vessel became inadvertently caught in the anastomosis. The overall survival rate for distal digital replants was 85% (6/7 replants). It is very difficult to evenly anastomose vessels of differing diameter, especially on a supermicrosurgical scale. In this respect, the IVaS method plays a role in stably anchoring the 2 vessel ends, allowing for the even spacing of suture knots, even in vessels of different caliber. Because of its ease of use and exactitude, many surgeons may be able to use the IVaS method to reliably complete small anastomoses in fingertip replantations.

Site Specific Evaluation of Lymphatic Vessel Sclerosis in Lower Limb Lymphedema Patients.

BACKGROUND: Histological changes in the collecting lymphatics in patients with lymphedema are classified as Normal type, Ectasis type, Contraction type, and Sclerosis type (NECST) classification. In this study, we investigated the condition of the lymphatic vessels in different sites of the legs. PATIENTS AND METHODS: We prospectively investigated the lymphatic vessels of patients with lymphedema who underwent lymphaticovenous anastomosis (LVA) from August 8, 2014 to August 4, 2015 based on the NECST classification. Lymphedema was diagnosed using lymphoscintigraphy, indocyanine green (ICG) lymphography, and the International Society of Lymphology (ISL) Classification. The affected limbs were divided into four sites: proximal thigh (Site 1), distal thigh (Site 2), proximal crus (Site 3), and distal crus (Site 4). RESULTS: A total of 109 patients (205 limbs and 1028 lymphatics) were included in this study. Of the 109 patients, there were 100 women and 9 men with an average age of 61 years. The ratio of Ectasis type vessels increased toward the distal end of the limb with the highest occurrence rate being 54% at Site 4. As ISL stage, ICG stage, and lymphoscintigraphy stage advanced, so too did the ratio of Sclerosis type. In secondary lymphedema patients with lymphedema, the ratio of Ectasis type was more predominant in the distal end of the limb, whereas this tendency was not observed in primary lymphedema patients. CONCLUSIONS: Sclerotic lymphatics are more predominantly found in the proximal limb whereas nonsclerotic vessels are more often found toward the distal end. These findings help lymphatic surgeon determine incision sites.

Multi-site lymphatic venous anastomosis using echography to detect suitable subcutaneous vein in severe lymphedema patients.

BACKGROUND: The method of lymphatic venous anastomosis (LVA), including its indications or preoperative examinations, has not been established. The purpose of this study is to reveal the possible application of preoperative echography in surgical LVA outcome. METHODS: We performed a retrospective case-control study on patients with lower limb lymphedema who underwent LVA between August 15, 2013 and August 15, 2014. As a preoperative examination, we used venous echography to identify subcutaneous veins in the echo group, while we only used Accuvein visualizing system in the control group. The operation time, number of anastomoses, and limb circumference were compared between the two groups. RESULTS: Seventeen patients (34 limbs) were included in the echo group, and 21 patients (42 limbs) were included in the control group. The average follow-up period was 11.9 (6-16) and 12.4 (6-27) months, respectively. The average operation time in the echo group was 258.6 min, and that in the control group was 216.5 min. The average number of anastomoses was 9.8 and 7.0 in the echo and control group, respectively. The average time per anastomosis was 27.4 and 32.6 min, respectively. The diameter of the vein had a tendency to be larger in the echo group than in the control group. In 5.8% of the echo group, we observed a circumference increase, compared with 23.8% in the control group. CONCLUSIONS: Preoperative venous echography allowed surgeons to increase the number of anastomoses performed within the operating time, resulting in improvement of surgical outcomes.

Lymph node transfer for refractory infectious sites caused by trauma.

OBJECTIVE: In this report, we placed focus on the immunological function of lymph nodes and performed lymph node transfer via a free flap to a site of refractory infection. CASE AND RESULTS: Case 1 describes a 34-year-old male suffering from compound fractures with severe crush injuries and burns in the right ankle joint. A 20 × 15 cm skin defect was observed around the right malleolus medialis, along with denuded tendons with bacterial infection. After conservative treatment, we transferred a lymph-node-containing free superficial circumflex iliac artery perforator flap to the region, with minimum debridement. No recurrence of wound infection appeared. Case 2 describes a 73-year-old male patient suffering from extensive contused wound in the right crus. Despite conservative treatment, the tibia gradually became denuded with computed tomography and magnetic resonance imaging revealing degeneration of the tibial cortex. We performed a free superficial circumflex iliac artery perforator flap containing lymph nodes to the chronic infection area. The wound area healed successfully. CONCLUSION: In conclusion, lymph node transfer has a potential of treatment infection sites.

Lymphaticovenous Anastomosis Releases the Lower Extremity Lymphedema-associated Pain.

BACKGROUND: We investigate the effectiveness of lymphaticovenous anastomosis (LVA) in releasing lymphedema-associated pain. METHODS: We performed a retrospective analysis. Subjects of this study included lower extremity lymphedema patients who presented persistent and constant degrees of pain in their lower limbs. LVA was performed under local anesthesia. The preoperative lower extremity pain and postoperative lower extremity pain were surveyed using the visual analog scale on a score from 0 to 10. The circumferences of the limbs were also recorded. RESULTS: A total of 8 patients (16 lower limbs) were included. The subjects included 1 man and 7 women, and their average age was 72 years. The average follow-up period was 17 months. The average preoperative and postoperative visual analog scale scores were 5.3 and 1.8, respectively. Moreover, 7 patients who had records of their lower extremity circumference observed an average changing rate of -4.7% in lower extremity lymphedema index after the surgery. CONCLUSION: LVA can release the pain in the affected limbs of lymphedema.

Superficial circumflex iliac artery pure skin perforator-based superthin flap for hand and finger reconstruction.

For hand and finger reconstruction, thin and flexible skin coverage is ideally required. A free flap is one of the surgical options used for large defects. However, a flap containing the fat layer is bulky. Several debulking surgeries are often needed for aesthetic and functional purposes. To overcome this disadvantage, we herein report our experience of six cases of hand and finger reconstruction using a pure skin perforator (PSP) flap concept. A PSP flap is a thin skin flap that is vascularized by a perforator branch penetrating the dermis. The thickness of the PSP flap could be approximately ≤2 mm as needed. The superficial circumflex iliac artery and superficial inferior epigastric artery were used as a flap pedicle. Secondary defatting operations were not required. For the success of PSP flap elevation, we applied three techniques: the microdissection technique for vessel separation, thin flap elevation at the superficial fascial layer, and the temporary clamping method. Temporary clamping was applied for the main trunk of pedicle vessels during debulking to prevent unwanted bleeding, which allowed us to freely perform three-dimensional defatting. Using these three techniques, the PSP flap can be elevated and adjusted for complex contouring of the hand and finger. Although the use of the PSP flap requires further study, the PSP flap is an effective, superthin flap with the advantages of both skin graft and perforator flaps.

Supermicrosurgical reconstruction for congenital aural atresia using a pure skin perforator flap: concept and long-term results.

BACKGROUND: Several surgical methods for creating an external auditory canal have been developed in step with clinical innovation. However, revision surgery is often required to address complications, which include external auditory canal stenosis, lateralization of the tympanic membrane, and chronic recurrent otorrhea. These complications occur frequently within 6 to 12 months after surgery. To decrease the incidence of complications, the authors reconstruct the external auditory canal and tympanic membrane in patients with congenital aural atresia using a free pure skin perforator flap that is as thin as a skin graft. They report their outcomes for hearing acuity and complications over 12 months after the operation. METHODS: The authors performed reconstruction of the external auditory canal and tympanic membrane in nine patients with congenital aural atresia. The flap design was based on a pure skin perforator derived from the groin area in eight patients. The flap was folded into an approximately 1.5×3-cm sac and inserted into the external auditory canal. Anastomosis was performed between the perforator vessels and superficial temporal vessels. RESULTS: All pure skin perforator flaps survived, although one case had partial epidermal necrosis. The audiologic follow-up period ranged from 12 to 24 months (mean, 17 months). The mean pure-tone average was 65.1 dB (range, 53 to 80 dB) preoperatively and improved to 32.4 dB (range, 8 to 53 dB) postoperatively. None of these cases showed any potential complications. CONCLUSION: This flap may therefore reduce complications and help to maintain hearing acuity in the long term. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Versatility of lateral cutaneous branches of intercostal vessels and nerves: anatomical study and clinical application.

The use of the intercostal artery perforator (ICAP) flap has recently become popular in reconstructions of the breast, upper arm and trunk. Lateral cutaneous branches (LCBs) are a group of the ICAPs that penetrate the fascia near the middle axillary line. However, reports on its precise anatomy and clinical applications are quite limited. We performed an anatomical study of LCBs using cadavers. Based on the findings, we developed novel clinical application methods as follows: (1) sensate superficial circumflex iliac perforator (SCIP) flap, (2) supercharged SCIP flap, (3) ICAP-based propeller flap (IBPF) and (4) free ICAP flap based on LCB. LCBs have the following advantages: (1) Long pedicles can be obtained in the supine position without risk of pneumothorax. (2) The neurovascular bundle is consistently available, allowing elevation of sensate flaps. (3) Donor-site morbidity is low. Therefore, we believe that LCBs offer a versatile option in reconstructive surgery.