Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic.

BACKGROUND: Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic. METHODS: Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA. RESULTS: LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed. CONCLUSION: LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.

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.

An extended superficial circumflex iliac artery perforator flap transfer for a relatively-small breast reconstruction after total mastectomy.

Superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has been applied in various reconstructions. Unlike traditional groin flap, SCIP flap has a longer pedicle and can be used as a chimeric flap for complex reconstruction. By utilizing both the superficial and the deep branches of the SCIA, a SCIP flap can be raised as an extended large bulky flap. Although there are many articles reporting usefulness of SCIP flap, there is no case reporting a large SCIP flap transfer for breast reconstruction after total mastectomy. We applied a free extended SCIP flap for a case of post-total-mastectomy breast reconstruction. A 51-year-old female who had undergone total mastectomy and sentinel lymph node biopsy was referred for autologous tissue breast reconstruction. Physical exam revealed that the iliac and lower abdominal regions were suitable for a donor site. As the patient desired to preserve a similar donor site for possible future contralateral breast reconstruction, the iliac region was selected as a donor site. A 23 × 15 cm SCIP flap was elevated based on the superficial and the deep branches of the SCIA, and was transferred to the recipient site. The SCIA and concomitant vein were anastomosed to the lateral thoracic artery and vein in an end-to-end fashion. Postoperative course was uneventful. The reconstructed breast shape and texture were similar to the contralateral breast with no donor site complication, and the patient was very satisfied with functionally and esthetically pleasing results. Extended SCIP flap may be an option for relatively-small breast reconstruction.

Free double-paddle superficial circumflex iliac perforator flap transfer for partial maxillectomy reconstruction: A case report.

Partial maxillectomy for maxillary sinus cancer treatment requires soft tissue reconstruction with enough bulk to occupy the large-volume defect. Deep inferior epigastric artery-based flaps and subscapular artery-based flaps are commonly used, but necessitate invasive muscle dissection or position change and a large recipient vessel. The aim of this report was to present a case of partial maxillectomy defect successfully reconstructed with a superficial circumflex iliac artery (SCIA) perforator (SCIP) flap, to address these drawbacks. A 67-year-old female underwent partial maxillectomy for maxillary sinus cancer. The defects included the medial and the caudal aspects of the maxillary sinus with unilateral palate loss. A double-paddle SCIP flap (19 × 9 cm and 10 × 6 cm) was elevated in a free-style manner based on the superficial branches of the SICA. The SCIP and its concomitant vein were anastomosed to a facial artery perforator and the angular vein with supermicrosurgical perforator-to-perforator anastomosis. Two skin paddles were utilized to reconstruct the defects of the nasal wall and the oral aspects of the palate. Postoperative course was uneventful, and the patient could resume normal oral diet 5 days after surgery. Three years after surgery, there was no cancer recurrence or any postoperative complication, and the patient was satisfied with normal speech and diet, and with concealable donor and recipient scars. Double-paddle SCIP flap transfer may be an option for reconstruction of a partial maxillectomy defect.

Indocyanine Green Lymphography for Evaluation of Breast Lymphedema Secondary to Breast Cancer Treatments.

BACKGROUND: Although breast lymphedema (BL) significantly deteriorates quality of life (QOL) of breast cancer survivors, little is known and pathophysiological severity staging system is yet reported. This study aimed to evaluate usefulness of a novel BL severity staging system based on indocyanine green (ICG) lymphography findings. METHODS: Breast cancer survivors with breast symptoms who underwent breast ICG lymphography were included. Breast ICG lymphography stage was determined based on visibility of linear pattern and extension of dermal backflow patterns. Prevalence of breast symptoms and lymphedema QOL score (LeQOLiS) was compared according to the stage. RESULTS: Thirty-seven patients were included. Breast ICG lymphography stage included stage 0 in 11 (29.7%) cases, stage I in 3 (8.1%) cases, stage II in 11 (29.7%) cases, stage III in 6 (16.2%) cases, stage IV in 4 (10.8%) cases, and stage V in 2 (5.4%) cases. Higher ICG stages were associated with more frequent prevalence of breast swelling (p = 0.020), breast pain (p = 0.238), and breast cellulitis (p = 0.024), and with higher LeQOLiS (p < 0.001). CONCLUSION: ICG lymphography allows clear visualization of superficial lymph circulation in the breast. Higher breast ICG lymphography stages are associated with more frequent prevalence of BL-related symptoms and worse QOL.

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.

A triple-component deep inferior epigastric artery perforator chimeric free flap for three-dimensional reconstruction of a complex knee defect complicated with patella osteomyelitis.

Reconstruction of a complex knee defect is challenging, especially when complicated with osteomyelitis. Complex knee defect requires multi-component three-dimensional reconstruction using a chimeric flap. Although anterolateral thigh (ALT) flap is the most workhorse chimeric flap, another chimeric flap is required when ALT flap is not available. In this report, we present a case of complex knee defect successfully treated with a free triple-component chimeric deep inferior epigastric artery perforator (DIEP) flap transfer. A 36 year-old male sustained right above-knee amputation and Gustilo IIIB open fracture of the left patella after being run over by a train. Stump formation was performed for the right limb amputation, and the left knee wound resulted in skin necrosis complicated with patella osteomyelitis. After debridement, the left knee wound showed a 3 × 2 cm articular capsule defect, 5 × 2 cm exposed patella stump, and a 16 × 9 cm skin defect. A triple-component chimeric DIEP flap, containing a 7 × 3 cm rectus abdominis muscle (RAM), a 3 × 2 cm RAM's fascia, and a 23 × 10 cm skin was transferred. The RAM's fascia was used to reconstruct the joint, the RAM to cover the exposed patella's stump and the reconstructed joint, and the skin paddle to cover the skin defect. Six months after the surgery, the patient could walk without osteomyelitis recurrence, and there was no limitation in the left knee joint's range of motion. Although indication is limited, a multi-component chimeric DIEP flap may be an option for three-dimensional reconstruction of a complex defect.

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.

Endothelial Robo4 regulates IL-6 production by endothelial cells and monocytes via a crosstalk mechanism in inflammation.

Roundabout4 (Robo4) is an endothelial cell-specific receptor that stabilizes vasculature in pathological angiogenesis. Previous studies have shown that Robo4 is a potential therapeutic target for inflammatory diseases, but its precise roles in inflammation remain unclear. To investigate physiological Robo4 functions in inflammation, we performed a loss-of-function study in vitro and in vivo using lipopolysaccharide (LPS)-induced endotoxemia models. Subcutaneous injection of LPS into Robo4-knockout mice reduced circulating IL-6 levels. siRNA-mediated Robo4 knockdown suppressed IL-6 production induced by LPS, IL-1ß, and TNFα, in human umbilical vein endothelial cells (HUVECs). Coculture experiments with HUVECs and a monocytic cell line, U937 cells, demonstrated that Robo4 knockdown suppresses IL-6 production by both endothelial cells and U937 cells. Further coculture experiments demonstrated that Robo4 knockdown inhibited a novel IL-6 amplification mechanism mediated by crosstalk between endothelial cells and U937 cells via direct interactions and two mediators, GM-CSF and IL-1ß. Taken together, we demonstrated novel Robo4 functions in inflammation, i.e., it promotes IL-6 production by endothelial cells and immune cells via crosstalk.

Localized Leg Volume Index: A New Method for Body Type-Corrected Evaluation of Localized Leg Lymphedematous Volume Change.

BACKGROUND: Volume measurement is one of the most common evaluations for lower-extremity lymphedema. However, volume comparison between different patients with different physique may be inappropriate, and it is difficult to evaluate localized limb volume change using leg volume evaluation. METHODS: Localized leg volumes (Vk, k = 1-5) and localized leg volume indices (LEVIk) at 5 points (1, thigh; 2, knee; 3, lower leg; 4, ankle; 5, foot) of 106 legs of 53 examinees with no leg edema were calculated based on physical measurements, leg circumferences and lengths, and body mass index (BMI). Interrater and intrarater reliabilities of LEVIk were assessed, and Vk and LEVIk were compared between lower BMI (BMI < 22 kg/m) group and higher BMI (BMI ≥ 22 kg/m) group. RESULTS: Interrater and intrarater reliabilities of LEVIk were all high (all: r > 0.98). Between lower and higher BMI groups, significant differences were observed in all Vk: V1 (P = 3.7 × 10), V2 (P = 4.7 × 10), V3 (P = 4.5 × 10), V4 (P = 1.6 × 10), and V5 (P = 2.4 × 10). Regarding LEVI between groups, significant differences were seen in LEVI3 (P = 0.009), LEVI4 (P = 0.004), and LEVI5 (P = 1.3 × 10); no significant difference was seen in LEVI1 (P = 0.23) or LEVI2 (P = 0.51). CONCLUSIONS: Localized leg volume index is a highly reproducible and convenient method for evaluation of localized volume change of the lower extremity, which is less affected by body type compared with leg volumetry.

Localized Arm Volume Index: A New Method for Body Type-Corrected Evaluation of Localized Arm Lymphedematous Volume Change.

BACKGROUND: Volume measurement is a common evaluation for upper extremity lymphedema. However, volume comparison between different patients with different body types may be inappropriate, and it is difficult to evaluate localized limb volume change using arm volume. METHODS: Localized arm volumes (Vk, k = 1-5) and localized arm volume indices (LAVIk) at 5 points (1, upper arm; 2, elbow; 3, forearm; 4, wrist; 5, hand) of 106 arms of 53 examinees with no arm edema were calculated based on physical measurements (arm circumferences and lengths and body mass index [BMI]). Interrater and intrarater reliabilities of LAVIk were assessed, and Vk and LAVIk were compared between lower BMI (BMI, <22 kg/m) group and higher BMI (BMI, ≥22 kg/m) group. RESULTS: Interrater and intrarater reliabilities of LAVIk were all high (all, r > 0.98). Between lower and higher BMI groups, significant differences were observed in all Vk (V1 [P = 6.8 × 10], V2 [P = 3.1 × 10], V3 [P = 1.1 × 10], V4 [P = 8.3 × 10], and V5 [P = 3.0 × 10]). Regarding localized arm volume index (LAVI) between groups, significant differences were seen in LAVI1 (P = 9.7 × 10) and LAVI5 (P = 1.2 × 10); there was no significant difference in LAVI2 (P = 0.60), LAVI3 (P = 0.61), or LAVI4 (P = 0.22). CONCLUSIONS: Localized arm volume index is a convenient and highly reproducible method for evaluation of localized arm volume change, which is less affected by body physique compared with arm volumetry.

Supermicrosurgical deep lymphatic vessel-to-venous anastomosis for a breast cancer-related arm lymphedema with severe sclerosis of superficial lymphatic vessels.

Lymphatic supermicrosurgery or supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular for the treatment of compression-refractory upper extremity lymphedema (UEL) with its effectiveness and minimally invasiveness. In conventional LVA, superficial lymphatic vessels are used for anastomosis, but its treatment efficacy would be minimum when superficial lymphatic vessels are severely sclerotic. Theoretically, deep lymphatic vessels can be used for LVA, but no clinical case has been reported regarding deep lymphatic vessel-to-venous anastomosis (D-LVA). We report a breast cancer-related UEL case treated with D-LVA, in which a less-sclerotic deep lymphatic vessel was useful for anastomosis but superficial lymphatic vessels were not due to severe sclerosis. A 62-year-old female suffered from an 18-year history of compression-refractory right UEL after right breast cancer treatments, and underwent LVA under local infiltration anesthesia. Because superficial lymphatic vessels found in surgical fields were all severely sclerotic, a deep lymphatic vessel was dissected at the cubital fossa. A 0.50-mm deep lymphatic vessel running along the brachial artery was supermicrosurgically anastomosed to a nearby 0.40-mm vein. At postoperative 12 months, her right UEL index decreased from 134 to 118, and she could reduce compression frequency from every day to 1-2 days per week to maintain the reduced lymphedematous volume. D-LVA may be a useful option for the treatment of compression-refractory UEL, when superficial lymphatic vessels are severely sclerotic. © 2015 Wiley Periodicals, Inc. Microsurgery 37:156-159, 2017.

Establishment of supermicrosurgical lymphaticovenular anastomosis model in rat.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is becoming a choice of treatment for compression-refractory lymphedema. However, LVA requires highly sophisticated microsurgical technique called supermicrosurgery, and no training model for LVA has been developed. This study aimed to develop and evaluate feasibility of a new LVA model using rat thigh lymphatic vessels. METHODS: Ten Sprague-Dawley rats were used for the study. After preoperative indocyanine green (ICG) lymphography, lymphatic vessels in posteromedial aspect of the thigh were dissected. In right limbs, the largest lymphatic vessel was anastomosed to the short saphenous vein or its branch, and the remaining lymphatic vessels were ligated (LVA group). In left limbs, all lymphatic vessels were ligated (control group). Anastomosis patency was evaluated intraoperatively and at postoperative 7 days. RESULTS: Courses of lymphatic vessels in the thigh were constant; lymphatic vessels run along the short saphenous vein. The mean diameter of lymphatic vessel used for LVA was 0.240 ± 0.057 mm, and the mean diameter of vein was 0.370 ± 0.146 mm. All lymphatic vessels were translucent and very thin like human intact lymphatic vessels. In LVA group, intra- and post-operative anastomosis patency rates were 100% (10/10) based on ICG lymphography. In control group, intra- and post-operative patency rates were 0% (0/10). CONCLUSIONS: Rat lymphatic vessels are thin, translucent, and fragile similar to intact human lymphatic vessels. The LVA model uses easily accessible lymphatic vessels in the thigh, and is useful for training of supermicrosurgical LVA. © 2014 Wiley Periodicals, Inc. Microsurgery 37:57-60, 2017.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type-Corrected Lower Extremity Volume Evaluation.

BACKGROUND: Volume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV). METHODS: Twenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20-25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups. RESULTS: The mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m, P < 0.001]. CONCLUSIONS: The LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type-corrected LV evaluation compared with volumetry-based evaluations.

Genital Lymphedema Score: Genital Lymphedema Severity Scoring System Based on Subjective Symptoms.

BACKGROUND: Genital lymphedema (GL) causes irritating symptoms such as urinary troubles due to genital edema and genital lymphorrhea, which deteriorate patients' quality of life. Indocyanine green genital lymphography has been reported to be useful for severity evaluation of GL but is not available in all medical settings. More convenient and simple severity evaluation methods are required in clinical practice. METHODS: Thirty-two female secondary lower extremity lymphedema patients with GL were evaluated using the genital lymphedema score (GLS) based on patients' symptoms related to GL (score from 0 to 9; higher is worse) and the genital dermal backflow (GDB) stage based on indocyanine green lymphography findings. The GLS was compared according to GDB stage. RESULTS: The GLS ranged from 1 to 9 (mean, 3.0), and GDB stage ranged from I to IV (9 in GDB stage I, 13 in GDB stage II, 8 in GDB stage III, and 2 in GDB stage IV). There was a significant difference between GLS in GDB stage I, GDB stage II, GDB stage III, and GDB stage IV [1.2 (0.4), 2.4 (0.5), 4.8 (0.9), and 8.0 (1.4), respectively; P < 0.001). CONCLUSIONS: The GLS was well associated with pathophysiological GL severity staging system and increased with progression of GDB stage. Because GLS is more convenient and simple than GDB stage, GLS is useful for primary evaluation of GL.

Relationship Between Lymphedema and Arteriosclerosis: Higher Cardio-Ankle Vascular Index (CAVI) in Lymphedematous Limbs.

BACKGROUND: Arteriosclerosis is one of the most important public health issues because it is very common in developed countries and its sequelae are lethal. Lymphatic vessel insufficiency has been reported to be associated with atherogenesis. Lymphedema seems to affect progression of arteriosclerosis, but no clinical study has been reported. METHODS: Forty-eight limbs of 24 female patients with pelvic cancer-related lower extremity lymphedema (LEL) were evaluated. Cardio-ankle vascular index (CAVI), an indirect estimate of the arterial stiffness, was measured in each limb. Cardio-ankle vascular index was compared according to known arteriosclerosis risk factors including age (younger than 65 years vs 65 years), body mass index (BMI; <25 vs 25 kg/m), hypertension (HT), diabetes mellitus, hyperlipidemia (HL), and smoking, as well as according to LEL-related factors including duration of LEL (<5 years vs 5 years), pelvic irradiation, leg cellulitis, LEL index (<250 vs 250), and leg dermal backflow (LDB) stage (LDB stage 0/I vs LDB stage II/III/IV/V) using univariable analyses and multivariable analysis. RESULTS: Univariable analyses revealed statistically significant differences in CAVI between lower BMI and higher BMI [7.19 (0.75) vs 8.36 (1.24), P < 0.01], HT (-) and HT (+) [7.25 (0.81) vs 8.17 (1.29), P < 0.01], HL (-) and HL (+) [7.19 (0.74) vs 8.06 (1.27), P < 0.01], and lower LDB stage and higher LDB stage [6.87 (0.65) vs 7.76 (1.05), P < 0.01]. Multivariable analysis revealed statistically significant differences in CAVI between lower BMI and higher BMI (P < 0.01), shorter duration of LEL and longer duration of LEL [7.21 (1.04) vs 7.71 (0.97), P = 0.04], and lower LDB stage and higher LDB stage (P = 0.04) CONCLUSIONS: Higher BMI, longer duration of LEL, and higher LDB stage were independent factors associated with higher CAVI in pelvic cancer-related LEL.

Efferent Lymphatic Vessel Anastomosis: Supermicrosurgical Efferent Lymphatic Vessel-to-Venous Anastomosis for the Prophylactic Treatment of Subclinical Lymphedema.

BACKGROUND: In lower extremity lymphedema secondary to pelvic cancer treatments, lymphedema develops despite that the inguinal lymph nodes (LNs) are preserved. Obstruction of the efferent lymphatic vessels of the inguinal LNs causes lower extremity lymphedema, and it is considered a radical treatment to bypass the efferent lymphatic vessel. METHODS: Efferent lymphatic vessel anastomosis, supermicrosurgical efferent lymphatic vessel-to-venous anastomosis, was performed on 14 legs with subclinical lymphedema [leg dermal backflow (LDB) stage I]. Efferent lymphatic vessel anastomosis was performed under local anesthesia at the groin region, and an efferent lymphatic vessel of the inguinal LN is anastomosed to a recipient vein. Feasibility and postoperative results were evaluated. RESULTS: All 14 efferent lymphatic vessel anastomoses were successfully performed without perioperative complication. All legs could be free from lymphedematous symptoms without perioperative compression at postoperative 1 year. Postoperative LDB stage included LDB stage 0 (n = 8) and LDB stage I (n = 6), which was significantly downstaged compared with preoperative LDB stage (P < 0.001). CONCLUSIONS: Efferent lymphatic vessel anastomosis allowed lymph flow bypass after filtration by the superficial inguinal LN through a skin incision along the inguinal crease, and was effective to prevent development of symptomatic lymphedema in subclinical lymphedema cases.

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-Type Corrected Arm Volume Evaluation.

BACKGROUND: Volumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. METHODS: Seventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees' BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m), middle BMI (BMI, 20-25 kg/m), and high BMI (BMI, >25 kg/m). Arm volume and UEL index were compared with corresponding BMI groups. RESULTS: Mean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5]. CONCLUSIONS: Arm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

Sensate superficial inferior epigastric artery flap innervated by the iliohypogastric nerve for reconstruction of a finger soft tissue defect.

In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap's region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN.