Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema.

BACKGROUND: Indocyanine green (ICG) lymphography is frequently used in the diagnosis of lymphedema, as well as the planning of its surgical management, but the typical anatomy of the superficial lymphatic pathways is incompletely delineated. This study aims to evaluate the topographical anatomy of superficial lymphatic vessels of the upper extremity METHODS: Sixty consecutive patients undergoing lymphaticovenular anastomosis for unilateral upper extremity lymphedema were selected. Lymphatic mapping was performed on the normal contralateral arm with ICG lymphography. A single upper arm reference line and two separate forearm reference lines (anterior and posterior) were drawn between anatomic landmarks. Lymphatic pathways were analyzed based on distances (cm) from the reference lines and were compared with those in lymphedema arms. RESULTS: Mean age of the patients were 54.6 ± 8.4 years. Three lymphatic flow pathways were identified: anterior (100%), posterior (96.6%), and posterior-ulnar lymphatic (33.3%) vessels. The anterior and posterior lymphatic vessels ran along the anterior and posterior reference lines, respectively, on the forearm (within 2 cm) and medial to the upper arm reference line. In arms with lymphedema, the absence of lymphatic flow was most commonly observed in posterior lymphatics (29/59, 49%), followed by anterior (15/60, 25%) and posterior-ulnar lymphatics (1/20, 5%). Compared to normal arms, new lymphatic flow through posterior-ulnar lymphatics was observed in 34.5% of patients (10/29) in whom posterior lymphatics was completely obstructed. CONCLUSIONS: Superficial lymphatic vessels can be classified into anterior, posterior, and posterior-ulnar lymphatic vessels. Posterior-ulnar lymphatic vessels might be least affected by lymphosclerosis in patients with lymphedema.

Factors influencing postoperative abdominal pain in DIEP flap breast reconstruction.

BACKGROUND: Identification of a subgroup of patients with severe postoperative pain is important for adequate pain management for enhanced, fast recovery after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The purpose of this study was to identify factors influencing postoperative abdominal pain in patients undergoing DIEP flap breast reconstruction. METHODS: Consecutive patients who underwent unilateral breast reconstruction using DIEP free flaps from October 2018 to July 2020 were included in this study. Visual analog scale (VAS)-guided postoperative pain scores were documented every 3 hours until 48 hours postoperatively. Factors affecting patient-reported pain scores were analyzed using a linear mixed-effects model. Independent variables included patient characteristics, history of previous open abdominal surgery, and operative factors including the flap size, flap weight, use of a unipedicled or bipedicled flap, number of perforators, timing of reconstruction, and use of a catheter-based subcutaneous plane block in the abdomen. A catheter was placed above the rectus fascia during closure, and analgesics were continuously infused during the 48 hours using an ON-Q Pain Relief System (I-Flow Co., Lake Forest, CA, USA). RESULTS: Fifty-five patients were included in the analysis. In the linear mixed effect model using multiple clinical variables, the harvested flap weight was significantly associated with the degree of pain (ß coefficient =0.157, P=0.008). The pain degrees significantly decreased according to postoperative days (ß coefficient =-0.649, P<0.001). The flap type (unipedicle or bipedicle), number of perforators, timing of reconstruction, and history of previous abdominal surgery did not influence pain degrees. The use of subcutaneous plane block did not affect the degree of pain or dose of analgesics used. CONCLUSIONS: A larger flap weight is associated with an increased degree of pain in patients undergoing DIEP flap breast reconstructions. Vigorous pain management might be necessary when a large flap is elevated.

When is the Critical Time for Soft Tissue Reconstruction of Open Tibia Fracture Patients?

BACKGROUND: The timing of soft tissue reconstruction for soft-tissue defect in patients with open fractures in the lower extremity is known to be critical for successful outcomes. However, medical advances, including development of dressing materials and refinement in the microsurgical techniques, might have undergone modifications in this "critical period." There have been no studies on the role of timing on reconstructive outcomes. Thus, we have analyzed the effect of reconstruction timing on optimal surgical outcomes and complication rates in a single type of lower extremity injury. METHODS: Data of patients who underwent microvascular free tissue transfer with an open fracture in the lower extremity from 2014 through 2016 were retrospectively reviewed (n = 103). Surgical outcomes, including flap complication rate, flap revision rate, and long-term bony complications, were analyzed serially in accordance with time interval until coverage using the receiver operating characteristic (ROC) curve analysis. Significant factors with a p < 0.05 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS: A total of 46 patients (33 males and 13 females) were finally included in the study. Based on the association between surgical timing and flap-related complication rate, the best cutoff period for surgery was 33 days, with an area under the curve of 0.658 (p = 0.040). Further, in the revision rate, the cutoff period was identified as 10 days (p = 0.016). Regarding the incidence of bony complications, ROC curve showed that the maximal period until operation was 91 days with no influence on the occurrence of bony complications (p = 0.029). CONCLUSION: Although the best method is an early reconstruction, many modalities such as negative pressure wound therapy play a role as a temporary measure. Our study suggests that the acute or early period for successful reconstruction might be extended compared with previous studies.

Pure hemi-periareolar incision versus conventional lateral radial incision mastectomy and direct-to-implant breast reconstructions: comparison of indocyanine green angiographic perfusion and necrosis of the nipple.

BACKGROUND: This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap. METHODS: Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes. RESULTS: A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P<0.001). No nipple perfusion pattern was a significant predictor for nipple-areola complex necrosis in univariable and multivariable analyses (P<0.001). There was no case of reconstruction failure. CONCLUSIONS: Immediate direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision can be safely performed using indocyanine green angiographic evaluation on the mastectomy skin flap.

Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction.

The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient's foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.

Comparison of the second and third intercostal spaces regarding the use of internal mammary vessels as recipient vessels in DIEP flap breast reconstruction: An anatomical and clinical study.

BACKGROUND: The purpose of this study was to compare the anatomical features of the internal mammary vessels (IMVs) at the second and third intercostal spaces (ICSs) with regard to their use as recipient vessels in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: A total of 38 consecutive DIEP breast reconstructions in 36 patients were performed using IMVs as recipient vessels between March 2017 and August 2018. The intraoperative findings and postoperative complications were analyzed. Anatomical analyses were performed using intraoperative measurements and computed tomography (CT) angiographic images. RESULTS: CT angiographic analysis revealed the mean diameter of the deep inferior epigastric artery to be 2.42±0.27 mm, while that of the deep inferior epigastric vein was 2.91±0.30 mm. A larger mean vessel diameter was observed at the second than at the third ICS for both the internal mammary artery (2.26±0.32 mm vs. 1.99±0.33 mm, respectively; P=0.001) and the internal mammary vein (IMv) (2.52±0.46 mm vs. 2.05±0.42 mm, respectively; P<0.001). Similarly, the second ICS was wider than the third (18.08±3.72 mm vs. 12.32±2.96 mm, respectively; P<0.001) and the distance from the medial sternal border to the medial IMv was greater (9.49±2.28 mm vs. 7.18±2.13 mm, respectively; P<0.001). Bifurcations of the IMv were found in 18.4% of cases at the second ICS and in 63.2% of cases at the third ICS. CONCLUSIONS: The IMVs at the second ICS had more favorable anatomic features for use as recipient vessels in DIEP flap breast reconstruction than those at the third ICS.

Lymphaticovenular Anastomosis for Treatment of Lymphedema Developed After Liver Transplantation: A Case Report.

OBJECTIVE: Secondary lymphedema of the extremities usually develops well after lymph node dissection or radiation therapy in oncologic surgery. In this report, we present a case of lymphedema developed after liver transplantation and treatment by lymphaticovenular anastomosis (LVA). METHODS: A 52-year-old man was diagnosed with hepatocellular carcinoma in April 2016, and a liver transplantation was performed in June 2016. After the liver transplantation, left lower leg swelling developed, and the symptom became severe for around a year. Two years after liver transplantation, lymphoscintigraphy and indocyanine green lymphography were performed, and the patient was diagnosed with lymphedema caused by proximal lymphatic obstruction. LVA was performed at the ankle and superior knee areas. RESULTS: The difference between the left and right knee circumference was decreased from 5.3 cm to 3.4 cm at 6 months postoperatively. The lower extremity lymphedema index of the left leg was decreased from 291.9 to 288.1 at 6 months after surgery. A quality of life measure for limb lymphoedema survey showed that all 4 categories (function, appearance, symptoms, and mood) were improved at 6 months after surgery. CONCLUSION: Lymphedema can develop after liver transplantation, and early LVA surgery can be effective for the treatment of lymphedema developed after liver transplantation.

No-fat diet for treatment of donor site chyle leakage in vascularized supraclavicular lymph node transfer.

Supraclavicular lymph node (SCLN) flap is a common donor site for vascularized lymph node transfer for the treatment of lymphedema. Chyle leakage is a rare but serious complication after harvesting SCLN flap in the neck. We report a case of chyle leakage at the SCLN donor site and its successful management. A 52-year-old woman underwent SCLN transfer for treatment of lower extremity lymphedema. After starting a regular diet and wheelchair ambulation on the 3rd postoperative day, the amount of drainage at the donor site increased (8-62 mL/day) with the color becoming milky, which suggested a chyle leak. Despite starting a low-fat diet on the 4th postoperative day, the chyle leakage persisted (70 mL/day). The patient was started on fat-free diet on the 5th postoperative day. The amount of drainage started to decrease and the drain color became more clear within 24 hours. The drainage amount remained less than 10 mL/day from the 8th postoperative day, and we removed the drain on the 12th postoperative day. There was no seroma or other wound complications at follow-up 4 weeks after the operation. The current case demonstrates that a fat-free diet can be a first-line treatment for low output chyle leakage after a SCLN flap.

Incidental finding of subclavian artery occlusion and subsequent hypoplastic internal mammary artery as a candidate recipient vessel in DIEP flap breast reconstruction.

We report a case of autologous breast reconstruction in which a thoracodorsal vessel was used as a recipient vessel after a hypoplastic internal mammary vessel was found on preoperative computed tomography (CT) angiography. A 46-year-old woman with no underlying disease was scheduled to undergo skin-sparing mastectomy and breast reconstruction using a deep inferior epigastric artery perforator flap. Preoperative CT angiography showed segmental occlusion of the right subclavian artery with severe atherosclerosis and calcification near the origin of the internal mammary artery, with distal flow maintained by collateral branches. The thoracodorsal artery was selected to be the recipient vessel because CT showed that it was of adequate size and was not affected by atherosclerosis. The patient experienced no postoperative complications, and the flap survived with no vascular complications. The breasts were symmetrical at a 6-month follow-up. This case highlights that preoperative vascular imaging modalities may help surgeons avoid using diseased vessels as recipient vessels in free flap breast reconstructions.