Simultaneous bilateral distal venous arterialization between redial artery and cephalic vein in dorsal hand for Raynaud's phenomenon in both hands: A case report.

Raynaud's phenomenon (RP) is characterized by episodic vasospasm in peripheral vessels and ischemia of the fingers. Venous arterialization is thought to induce neovascularization and increased oxygen tension. In this report, we describe a patient with RP in the fingers of both hands in whom venous arterialization achieved an acceptable result in both hands. The patient was a 62-year-old woman with a 10-year history of worsening pain and cold sensation in the tips of the index, middle, ring, and little fingers on both sides. The venous arterialization procedure was performed on both hands simultaneously at the level of the anatomical snuff box between radial artery and cephalic vein in dorsal hand. There was no need for valvectomy in the level of hands. To prevent development of the steal phenomenon in the arterialized veins, the superficial basilic and median veins of the forearm were ligated via 1 cm skin incisions. The pain and cold sensation in the fingertips of both hands remained decreased, and the nonhealing ulcers on the fingertips healed without the need for amputation. The observation period was 14 months, and the surface temperature of the fingers was increased after venous arterialization, as was the temperature of the palm and forearm. There was no problem when administering intravenous infusion into the forearm on either side postoperatively. The case showed venous arterialization was effective for RP without increasing intravenous pressure in the affected limb, and further investigation is necessary.

Sural communicating nerve for application as a vascularized nerve graft: A microneurovascular anatomic study in cadavers.

INTRODUCTION: Sural nerve harvest causes paraesthesia to the lateral heel of the foot, which can debilitate those with already compromised proprioception. To circumvent this, we investigated an alternative donor nerve, branch of the lateral sural nerve complex called the sural communicating nerve (SCoNe), for its harvest and use as a vascularized nerve graft, in cadaver. METHODS: The SCoNe was visualized by dissection in 15 legs from 8 human cadavers and the relationship of the SCoNe to the overall sural nerve complex was documented. The surface markings, dimensions, and the micro-neurovascular anatomy in the super-microsurgery range (up to 0.30 mm) of the SCoNe was recorded and analyzed. RESULTS: SCoNe graft surface marking was confined within a triangle drawn between the fibular head laterally, the popliteal vertical midline medially and the tip of the lateral malleolus inferiorly. The proximal end of the SCoNe was situated at a mean intersection distance of 5 cm from both the fibular head and popliteal midline respectively. The mean length of the SCoNe was 226 ± 43 mm with a mean proximal diameter of 0.82 mm and mean distal diameter of 0.93 mm. In 53% of the cadavers, an arterial input was present in the proximal third of the SCoNe and veins were predominantly (87%) present in the distal third. In 46% and 20% of the 15 legs respectively, there was a nutrient artery and vein perfusing the SCoNe in its central segment. The external mean diameter of this artery was 0.60 ± 0.30 mm, while the vein was slightly larger with a mean diameter of 0.90 ± 0.50 mm. DISCUSSION: SCoNe graft may preserve lateral heel sensation, compared to sural nerve harvest, pending clinical studies. It may have wide applications as a vascularized nerve graft, including being ideal as a vascularized cross-facial nerve graft because its nerve diameter is similar to the distal facial nerve branches. The accompanying artery is a good anastomotic match to the superior labial artery.

Osteocutaneous superficial circumflex iliac perforator flap for the lower extremity bone and soft tissue reconstruction with perforator-to-perforator anastomosis after radical debridement of tibia osteomyelitis: A case report.

Reconstruction of soft tissue and bone defects in tibia chronic osteomyelitis is challenging and often managed by free flap with bone graft. However, the use of osteocutaneous free flap combined with perforator-to-perforator anastomosis has not been reported. We report the case of a 62-year-old man presenting with soft tissue and bone defects with right tibial chronic osteomyelitis, which was successfully treated with an osteocutaneous superficial circumflex iliac perforator (SCIP) flap with perforator-to-perforator anastomosis. After radical debridement and excision of the sequestrum, a 17 × 10-cm skin defect and a 4 × 3-cm bone defect remained. An osteocutaneous SCIP flap, containing a 16 × 9-cm skin paddle and 4 × 2-cm iliac bone, was transferred and anastomosed to the posterior tibial perforator in an end-to-end fashion. An artificial dermis was placed to cover the soft tissue. At 1 week postoperatively, the artificial dermis was partially infected, which required small debridement. Full weight-bearing was permitted 5 weeks postoperatively, and the patient walked independently. No evidence of recurrence of osteomyelitis or skin ulcers was observed at 15 months postoperatively. Therefore, osteocutaneous SCIP flap with perforator-to-perforator anastomosis may be a potential alternative treatment for soft tissue and bone defects after radical debridement of tibia osteomyelitis.

Combined Revascularization and Free Flap Reconstruction for Chronic Limb-Threatening Ischemia: A Systematic Review and Meta-Analysis.

BACKGROUND: Combined revascularization and free flap reconstruction is one treatment method for chronic limb-threatening ischemia (CLTI) with complex wounds. The purpose of this systematic review and meta-analysis was to investigate the characteristics of this combined procedure and to assess postoperative outcomes. METHODS: A systematic search was performed across PubMed, Scopus, and the Web of Science for studies between January 2000 and February 2022. A random-effects meta-analysis for postoperative outcome was conducted. RESULTS: Fifteen articles encompassing 1,176 patients with 1,194 free flaps were ultimately included in the qualitative and quantitative assessment. Our meta-analysis showed the following complication rates for short-term postoperative outcomes: 37% (95% confidence interval [CI], 18-53%; I 2 = 74%) for reoperation, 13% (95% CI, 2-24%; I 2 = 0%) for vascular thrombosis, 9% (95% CI, 0-17%; I 2 = 0%) for total flap failure, 8% (95% CI, 0-17%; I 2 = 0%) for partial flap failure, 4% (95% CI, 0-10%; I 2 = 0%) for amputation, and 3% (95% CI, 0-9%; I 2 = 0%) for 30-day mortality. The 1-, 3-, and 5-year limb salvage rates were 86% (95% CI, 78-92%), 81% (95% CI, 68-88%), and 71% (95% CI, 53-83%), respectively. The 1-, 3-, and 5-year patient survival rates were 93% (95% CI, 90-96%), 92% (95% CI, 77-97%), and 75% (95% CI, 50-88%), respectively. CONCLUSION: Combined revascularization and free flap reconstruction for CLTI with complex wounds was clearly effective for the long-term outcomes. However, this combined procedure should be considered on the assumption that the reoperation rate is high and that flap-related complications rate may be higher than lower extremity reconstruction of other etiologies.

Finger Reconstruction With Distally Based Dorsal Metacarpal Flaps: A Systematic Review.

BACKGROUND: Distally based dorsal metacarpal flaps for the reconstruction of finger soft-tissue defects are classified into 3 categories: dorsal metacarpal artery perforator flap, reverse dorsal metacarpal artery (RDMA) flap, and extended reverse dorsal metacarpal artery (ERDMA) flap. The present systematic review aimed to evaluate differences in the outcomes of commonly encountered defects and postoperative complications among these three flaps. METHODS: PubMed, Scopus, and Web of Science were systematically searched from when the flats were first reported to May 2021. Random-effects meta-analysis for each outcome was performed, and 24 studies were included in the analysis. RESULTS: Dorsal metacarpal artery perforator flaps were mainly used for defects extending to the proximal interphalangeal joint (n = 62 [29.1%]) and proximal phalanx (n = 85 [39.9%]). Conversely, defects extending to the distal phalanx (n = 24 [43.6%]) were mostly reconstructed using the ERDMA flap. The rate of venous congestion was highest for the ERDMA flap (29.3%; 95% confidence interval [CI], -17.2% to 65.1%; I2 = 0%) and lowest for RDMA flap (8.1%; 95% CI, -5.9% to 21.7%; I2 = 0%). The RDMA flap showed the lowest rate of any short-term complications, including partial and total necrosis (6.6%; 95% CI, -6.8% to 19.8%; I2 = 0%). CONCLUSIONS: This systematic review demonstrated that the dorsal metacarpal artery perforator flap was suitable for reconstruction proximal to the middle phalanx, and the ERDMA flap was suitable for reconstruction distal to the distal interphalangeal joint. Although the RDMA flap showed the lowest rate of short-term complications and limited analysis was secondary to limited data available, these occurred in 6.6% to 10.9% of distally based dorsal metacarpal flaps.

Selection of deep or superficial recipient vein in lower extremity reconstruction using free flap: A systematic review and meta-analysis.

BACKGROUND: Free flap surgeries are useful procedures for lower-extremity reconstruction. Recipient vein selection for anastomosis is important to avoid venous congestion and thrombosis. Although deep or superficial venous system can be used as a recipient vein site, there is a lack of consensus on which system would be superior to avoid postoperative complications. This systematic review and meta-analysis aimed to assess the differences in outcomes between deep and superficial vein anastomosis for lower-extremity free flap reconstruction. METHODS: The PubMed, Scopus, Web of Science, and Cochrane Library medical databases were systematically searched from inception to April 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. A comparative meta-analysis was conducted on studies of deep and superficial venous system anastomosis outcomes, comprising vascular thrombosis, reoperation, complete flap necrosis, and any flap necrosis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was present. RESULTS: Six studies with 789 flaps were included in the analysis and qualitative and quantitative syntheses. The rate of vascular thrombosis (8.2% vs. 15.1%; p = .005) was significantly lower for flaps involving deep vein anastomosis than for those involving superficial vein anastomosis. The rate of reoperation after deep vein anastomosis was lower than that after superficial vein anastomosis, with no statistically significant difference (9.0% vs. 14.7%; p = .06). There were no significant differences in the rates of complete (2.5% vs. 2.0%; p = .90) or any flap necrosis (7.0% vs. 9.8%; p = .20). CONCLUSION: Deep vein anastomosis might be recommended for avoiding vascular thrombosis.

Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis.

BACKGROUND: Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes. METHODS: A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was identified. RESULTS: Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p = 0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p = 0.98), complete flap necrosis (6.2% vs. 4.7%; p = 0.30), infection (19.4% vs. 14.7%; p = 0.18), non-union (18.9% vs. 14.8%; p = 0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p = 0.69). CONCLUSION: This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.

An Ideal Choice for Closure of Large Free Radial Forearm Flap Donor Site Using a Local Full-Thickness Skin Graft.

ABSTRACT: The local full-thickness skin graft (FTSG) method based on the V-Y closure is reported to be the most convenient and reliable technique for free radial forearm flap (FRFF) donor site closure. The spindle-shaped FTSG was the most common local closure method in free osteofasciocutaneous fibula flaps but not FRFF reconstructions, despite being conveniently applicable to FRFF donor sites. The authors devised a spindle-shaped FTSG harvested from the ipsilateral radial forearm as a new concept in repairing the FRFF donor site. This procedure was performed on 4 patients and the average flap defect size was 5.0 × 8.3 cm (41.3 cm 2 ). The spindle-shaped FTSG is more likely to adapt to longer FRFFs, while a V-Y closure is more likely to adapt to wider ones. It is desirable to use both FTSGs properly depending on the large FRFF shape.

International Microsurgery Club Webinar Series-Bridging the Knowledge Gap during the COVID-19 Pandemic.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) outbreak shut down most conferences. To minimalize the influence, virtual meetings sprang up subsequently. International Microsurgery Club (IMC), as one of the largest professionals-only online microsurgery education groups worldwide, began to host regular weekend webinars during the pandemic to fill the knowledge gap. This study aims to discuss how webinars have fundamentally changed the way knowledge is delivered and exchanged. METHODS: From February 29, 2020 to March 14, 2021, 103 IMC webinars were reviewed and analyzed in detail to determine the use, benefit, and effect. A comparison between webinars hosted by the different societies was made as well. A questionnaire survey focusing on attendees' behavior, attitude, and using habit about webinars was also made. RESULTS: As for the 103 IMC webinar events, the peak participants were 112.3 people in average. The members requesting to join IMC abruptly increased during the pandemic, and the group activity increased dramatically. From the questionnaire (n = 68), the satisfaction level was high (8.88 ± 1.18/10). The respondents were most satisfied with the good quality of the speakers (73.5%). Not only hosts our webinar series but IMC also serves as the platform that welcomes webinars from other societies to share their information. In September 2020, International Microsurgery Webinar League was established via the significant webinar hosts, with more than 300 recorded webinar talks connected successfully. CONCLUSION: As the knowledge revolution driven by COVID-19 will continue, IMC will keep playing an essential role in exploring new and emerging opportunities to improve knowledge dissemination worldwide beyond the space-time boundary.

Investigation of flow velocity in recipient perforator artery for a reliable indicator for the flap transfer with perforator to perforator anastomosis.

INTRODUCTION: In flap transfer with perforator to perforator anastomosis (FTPPA), encountering poor pulsation and blood flow in a recipient perforator intraoperatively often makes FTPPA impossible. This study sought to identify color and spectral Doppler ultrasonography (CSDUS) parameters that can aid reliable preoperative selection of a recipient perforator artery. PATIENTS AND METHODS: The study enrolled 38 patients with lower extremity lymphedema who underwent vascularized lymphatic tissue transfer with perforator to perforator anastomosis for physiological lymphatic flow reconstruction. In all cases, three candidate recipient perforators were searched in each lower extremities, and vessel diameter and peak systolic flow velocity (PSFV) were measured. The inclusion criteria for candidates were a vessel diameter of >0.5 mm and a PSFV of >10 cm/s. These measures were compared with intraoperative findings, diameters and if there was pulsation and visible spurting evident. RESULTS: A total of 114 candidates were selected, and 52 of the candidates were dissected until suitable perforators were found. PSFV (cm/s) on CSDUS was ≥20.0 in 32 perforators (84.2%) and was 15.0-19.9 in 6 perforators (15.8%) in the group with pulsation and visible spurting evident, and 15.0-19.9 in one perforator (7.1%) and ≤ 14.9 in 13 perforators (92.9%) in the group without pulsation and visible spurting evident. There was a statistically significant correlation between preoperative PSFV and intraoperative pulsation and visible spurting evident after dissection (P = 0.021 × 10-3 ). The flap survival rate was 92.1%. CONCLUSION: PSFV is an important preoperative determinant of the suitability of a recipient perforator artery for FTPPA.

Combined Tissue Transfer for Extensive Lower Limb Complex Defects: Flow-through Flaps, Chimera, and "Orochi" Flaps.

Perforator flaps can be raised anywhere in the body, with minimal donor-site deformity, and can be made into custom-made combined composite flaps, especially for severe complex defects such as osteomyelitis of the lower limbs. Here, we report on the representative application of the combined tissue transfers for complex leg defects. For a wide range of complex defects in the lower extremity, it is necessary to perform reliable revascularization by bypass or flow-through type or vein graft. At the same time, a chimeric or "Orochi" type combined transfer using a minimally invasive perforator flaps and a well-vascularized bone flap are useful. In the case of nerve palsy, it could be possible to combine vascularized nerve flaps. Combined tissue transfers with less invasive donor will be more available in the future.

Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery.

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.

A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps: Extended Indications and Technical Modifications.

BACKGROUND: The current study introduces and demonstrates our experience of using a sequential thoracoacromial artery perforator (TAAP) flap to repair the sternocleidomastoid (SCM) flap donor site in this context. The aims of this technique are to optimize both esthetic and functional outcomes and to reduce postoperative complications for patients. METHODS: Between September 2013 and March 2017, the SCM flap combined with sequential TAAP flap was used for reconstruction postradical parotidectomy in 12 patients. Flap characteristics, patient outcomes, and postoperative complications were monitored and objectively measured, with 10 to 24 months of follow-up. RESULTS: There were no incidences of total flap loss. All TAAP flap donor sites were closed directly, and all healed without any complications. The SCM flap and TAAP flap donor areas were esthetically acceptable, with good esthetic and functional outcomes achieved in all 12 patients. CONCLUSIONS: The sequential TAAP flap has a consistent vascular supply and provides a reliable surgical approach to reconstruct the SCM flap donor site with good esthetic and functional outcomes.

Microscope-Induced Thermal Burns During Lymphaticovenular Anastomosis.

Bright illumination sources using xenon lamps have improved microsurgical visualization under an operating microscope; however, surgeons must recognize the potential for accidental thermal damage to soft tissues.In this article, we present 2 reports of microscopic thermal burn in lymphaticovenular anastomosis (LVA).A 23-year-old woman and a 57-year-old woman with bilateral lymphedema of the legs had LVAs on both legs under local anesthesia. The burn wound in a 23-year-old woman was full thickness, and the one in a 57-year-old woman was deep dermal burn. Both of them healed without skin grafting.Working distance and high illumination intensity are important risk factor. The use of epinephrine as part the local anesthetic mixture that decreases blood flow is also a major risk factor for thermal burns. Lymphaticovenular anastomosis particularly requires high magnification, which leads to increasing the intensity and decreasing the working distance. The surgical conditions around LVA are inherently prone to microscope-induced thermal burns.

Mechanical Dilation With a Nylon Monofilament for 0.1-mm Anastomoses.

Despite advances in supermicrosurgical techniques, the ability to anastomose vessels with a diameter of less than 0.2 mm remains limited. One of the reasons for this limitation is that the dilation methods currently available, such as inserting the tip of a microforceps into the lumen or topical application of a vasodilator such as papaverine hydrochloride or xylocaine spray, are not effective in very small vessels. To overcome this problem, we have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as a dilator. Using this method, a smaller nylon monofilament is inserted into the vessel as a guide before inserting a larger nylon monofilament as a dilator. After the smaller guide monofilament has been inserted, it is then much easier to insert another monofilament for dilation, even if it is a larger one. Using this method, even a vessel with a diameter of less than 0.1 mm could be dilated to greater than 0.2 mm. The dilator monofilament can also be used as an intravascular stent in the anastomosis. We have found that anastomosis of vessels with a diameter of less than 0.1 mm is possible using this method. In our experience, the immediate patency rate has been 100%. We believe mechanical dilation with a nylon monofilament is helpful for supermicrosurgery and even ultramicrosurgery.

Mechanical Dilation Using Nylon Monofilament Aids Multisite Lymphaticovenous Anastomosis Through Improving the Quality of Anastomosis.

Lymphaticovenous anastomosis (LVA) is now a common treatment for lymphedema. It is important to create as many bypasses as possible to maximize the efficacy of LVA. We have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as dilators. We refer to this technique as mechanical dilation (MD) to distinguish it from intravascular stenting. In this study, we investigated the efficacy of the conventional supermicrosurgery technique performed with and without MD as a treatment for lower limb lymphedema. The LVA was performed using conventional supermicrosurgery alone in 10 patients (group without MD) and in combination with MD in another 10 patients (group with MD). The mean number of successful LVAs performed per hour was significantly higher in the group with MD than in the group without MD (1.42 ± 0.16 vs 1.14 ± 0.15; P < 0.05). The mean amount of improvement in the lower extremity lymphedema index was significantly greater in the group with MD than in the group without MD (7.34 ± 1.57 vs 4.41 ± 1.53; P = 0.003 < 0.05). A statistically significant correlation was found between the number of successful LVAs and amount of improvement in lymphedema (r = 0.449, P = 0.047 < 0.05). Our findings suggest that use of MD does not shorten the operating time or increase the number of LVAs that can be performed but may make it possible to increase the number of successful LVAs that can be performed between vessels with a diameter of less than 0.3 mm. Use of MD could increase the improvement rate of lymphedema to a greater extent than that achieved by conventional microsurgery alone.

Successful treatment of breast cancer-related breast lymphedema by lymphovenous anastomosis in a male patient.

Men, as well as women may develop breast lymphedema following breast cancer treatment. Microsurgically performed lymphovenous anastomosis (LVA), an effective treatment for lymphedema of the extremities, has also been successfully applied to breast lymphedema. Here we report the first case of breast lymphedema secondary to male breast cancer, treated with supermicrosurgical LVA. A 48-year-old man presented with breast lymphedema following mastectomy, axillary lymph node dissection, and adjuvant radiotherapy. After the oncological treatments, the patient reported a sensation of tension, pain, and swelling of the left breast. The diagnosis of breast lymphedema was confirmed by lymphoscintigraphy. Since conservative treatment with manual lymphdrainage was ineffective, we performed LVAs at the left breast region. In total, two lymph vessels were anastomosed to two nearby veins. Immediately following this intervention, the left breast and lateral thorax region decreased in size and the sensation of tension disappeared. One year postoperative there was no recurrence of the swelling and the patient was very satisfied with the result. Although more reports are needed to confirm its efficacy, supermicrosurgical LVA appears to be a valuable treatment option for breast lymphedema in both women and men.

Lymphaticovenular anastomosis and venous arterialization in coexisting Raynaud's phenomenon and lymphedema: A case report.

Raynaud's phenomenon is highly prevalent in the general population. The optimal medical management for patients with severe Raynaud's phenomenon remains unclear. Venous arterialization (VA) may be considered as a salvage procedure when no distal vessels are available for vascular reconstruction. Surgical treatments for lymphedema, including lymphovenous anastomosis (LVA), are becoming popular alternatives to conservative therapy. Here, we report on a patient with comorbid primary Raynaud's phenomenon and lymphedema in whom both VA and LVA were performed. The patient was a 60-year-old woman with an edematous right upper limb and pain and cold sensitivity in the middle, ring, and small fingers that was refractory to medication. Indocyanine green lymphography and computed tomography angiography suggested coexistence of lymphedema and primary Raynaud's phenomenon. VA and LVA were performed to reduce the risks of cellulitis and amputation. Computed tomography angiography was performed regularly after surgery to examine the arterialized venous system and Doppler echography to search for developing branches. Five months later, three branches of the arterialized veins that flowed proximally at the level of the hand and wrist were ligated. By around 1 year after surgery, the lymphedema index in the affected upper limb had improved from 116 to 103 and the patient's numerical rating scale score for intractable pain and cold sensitivity had improved from 6-7 to 1-2. We believe that the combination of VA and LVA in the early stages of primary Raynaud's phenomenon and lymphedema was effective in this case.

Lymphatic supermicrosurgery for the treatment of recurrent lymphocele and severe lymphorrhea.

BACKGROUND: Lymphocele and lymphorrhea are frequent complications after lymph node excision. Recurrent lymphoceles and intractable lymphorrhea are particularly difficult to treat conservatively. We describe the outcomes of four patients with recurrent lymphocele and nine patients with persistent lymphorrhea that were treated by supermicrosurgery. METHODS: Four patients with recurrent lymphoceles with a size between 7 and 21 cm and located in the groin (n = 1) or upper leg (n = 3), were referred for surgical treatment between 2013 and 2017 after unsuccessful conservative therapy. Nine patients with lymphorrhea from the groin (n = 7), scrotum (n = 1), or axilla (n = 1) after lymph node or lipoma excision were referred for surgical treatment. Of these, five patients presented with a drainage system and two had a lymphocutaneous fistula. Indocyanine green (ICG) lymphography was used to visualize the lymphatic flow toward the lymphocele, to detect ruptured lymph vessels causing lymphorrhea and for preoperative lymphatic mapping. RESULTS: All 13 patients were successfully treated by one or more (mean: 3, range 1-4) lymphaticovenous anastomoses without perioperative complications. The lymphoceles resolved in all four patients, and no recurrence was recorded during follow-up. The lymphorrhea was cured in all patients by means of lymphaticovenous anastomosis performed distal to the site of leakage. No recurrence was observed during follow-up. The patency of the lymphaticovenous anastomosis was confirmed intraoperatively by means of ICG lymphography in all cases. CONCLUSION: Lymphaticovenous anastomosis is a minimally invasive and effective procedure for the treatment of recurrent lymphocele and persistent lymphorrhea.

Impact of Social Media on Current Medical Conferences.

BACKGROUND: Medical conferences are forums for research, continuing medical education, and networking. Social media is increasingly used for communication and networking due to its low cost and ability to overcome large distances. This study investigates the impact that social media brings to the current conference system. METHODS: There are three parts of this study: (1) comparing two similar brachial plexus injuries (BPIs) courses without (2009) and with (2017) social media support, and the participants' feedback; (2) sharing our experiences in the management of the 2018 International Course on SuperMicrosurgery (ICSM) conference; and (3) evaluating the studies from the social media platform International Microsurgery Club (IMC), for the consensus pertaining to social media and conference system. RESULTS: With the help of social media, international attendance increased during the 2017 BPI conference compared with the 2009 BPI course (25 nationalities in 2009 vs. 35 in 2017). At least 23% obtained their meeting information through social media. Live surgery was the overall main attraction (79%). The 2018 ICSM meeting revealed that video posts increased attendance; videos that were the most effective in attracting (viewership) were either short or pertained to surgical procedures. Facebook, Messenger, and WeChat smartphone applications were effective for immediate communication and troubleshooting among the participants. From the IMC polls, 78% believe that the social media and the conference complemented each other. 97% attended the conference to update their skills and knowledge. CONCLUSION: Social media is a quick and economic tool in promoting medical conferences and instant messenger systems offer immediate communication amongst associates. Despite the popularity of social media, the conference still has its irreplaceable role. The combination of the conference and the social media enhances the training and education of microsurgeons.