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.

Advanced Technical Pearls for Successful Supermicrosurgical Lymphaticovenular Anastomosis.

ABSTRACT: Lymphaticovenular anastomosis (LVA) is now accepted as one of the mainstays of surgical treatment of lymphedema. The unique advantages of LVA that set it apart from other procedures such as vascularized lymph node transfer are its safety and its minimally invasive nature. To date, there has been no report of worsening of disease as a result of LVA, even when performed unsuccessfully. Despite these notable advantages, the procedure is much less frequently performed compared with vascularized lymph node transfer because of inconsistent procedural outcome. In our experience, LVA is highly effective when performed with proper patient selection and meticulous technical execution. In this article, we share the senior author's LVA "tips and tricks" to help readers achieve greater success when performing this extraordinary supermicrosurgical procedure.

How to Get Started Performing Supermicrosurgical Lymphaticovenular Anastomosis to Treat Lymphedema.

Recent advancements in microsurgery and supermicrosurgery have made effective lymphedema treatment a surgical reality. When comparing the 2 currently available procedures, lymphaticovenular anastomosis (LVA) and vascularized lymph node transfer, vascularized lymph node transfer is more frequently performed owing to technical unfamiliarity with supermicrosurgery and uncertainty in patient selection, technical execution, and procedural outcome. To date, the author has performed more than 250 cases of supermicrosurgical LVAs. In this article, the author shares his approach in technical acquisition, how to get over the learning curve using a simulation model, patient selection, LVA-specific technical pearls, outcome assessment, and finally how to team up with other lymphedema-related specialists. After reading this paper, the readers should have enough knowledge to get started building a surgical lymphedema program.

Indocyanine Green Lymphographic Evidence of Surgical Efficacy Following Microsurgical and Supermicrosurgical Lymphedema Reconstructions.

Background Microsurgical vascularized lymph node transfer (VLNT) and supermicrosurgical lymphaticovenular anastomosis (LVA) are increasingly performed to treat lymphedema. The surgical outcome is commonly assessed by volume-based measurement (VBM), a method that is not consistently reliable. We describe indocyanine green (ICG) lymphography as an alternative postoperative tracking modality after lymphatic reconstruction with VLNT and LVA. Methods VLNT and LVA were performed in patients with therapy-refractory lymphedema. Patients were evaluated qualitatively by clinical assessment, quantitatively with VBM, and lymphographically using ICG lymphography. The evaluation was performed preoperatively, and at 3, 6, and 12-month postoperatively. Results Overall, 21 patients underwent lymphatic reconstruction with either VLNT or LVA. All reported prompt and durable relief of symptoms during the study period. All experienced disease regression based on the Campisi criteria. Out of the 21 patients, 20 (95%) demonstrated lymphographic down staging of disease severity. Out of the 21 patients, 3 (14%) developed a paradoxical increase in limb volume based on VBM despite clinical improvement. Conclusions ICG lymphography correlated highly with patient self-assessment and clinical examination, and is an effective postoperative tracking modality after lymphatic reconstruction.

Technical simplification of the supermicrosurgical side-to-end lymphaticovenular anastomosis using the parachute technique.

BACKGROUND: Supermicrosurgical side-to-end (S-E) lymphaticovenular anastomosis (LVA) is the most favorable anastomotic configuration for the treatment of lymphedema because it creates antegrade and retrograde lymph flow while preserves the native lymph flow. However, it is technically demanding and its successful performance has been limited only to the experienced LVA surgeons. This study aimed to evaluate the applicability of parachute technique in S-E LVA and its potential in decreasing the technical complexity of the procedure. METHODS: Between April 2010 and July 2011, S-E LVAs were performed in 14 patients with bilateral lower limb lymphedema with either the conventional technique or the parachute technique. To exclude interoperator variability of LVAs, only limbs in which S-E LVAs performed by one surgeon were included. Feasibility, anastomotic patency, operative times, and treatment efficacy of both techniques were retrospectively compared. RESULTS: Thirty-seven S-E LVAs were performed by the surgeon; 17 LVAs with parachute technique in seven limbs and 20 LVAs with the conventional technique in seven limbs. Both groups demonstrated 100% anastomotic patency. Time required to perform the S-E anastomosis using the parachute technique was significantly shorter than when the conventional technique was used (8.6 ± 3.7 vs. 11.3 ± 3.1 minutes, P = 0.025). Both groups showed similar postoperative reduction in lymphedema indices (19.9 ± 8.2 vs. 18.9 ± 10.0, P = 0.841). CONCLUSIONS: The parachute technique simplifies the supermicrosurgical S-E LVA while maintaining efficacy comparable to the conventional technique.

The "Octopus" Lymphaticovenular Anastomosis: Evolving Beyond the Standard Supermicrosurgical Technique.

BACKGROUND: Supermicrosurgical lymphaticovenular anastomosis (LVA) is a promising treatment modality for lymphedema. However, its practice is restricted by the surgeon/equipment-related factors, and its effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of a modified "octopus" LVA technique in addressing the above problems. METHOD: Nine consecutive lymphedema patients underwent LVA procedure using the "octopus" technique. Six had the upper extremity disease; three had the lower extremity disease. Except for one patient having primary lower extremity lymphedema, all had secondary disease related to cancer treatment. Disease severity ranged from Campisi stage Ib to IV. Qualitative and quantitative assessments were performed preoperatively, at 1, 3, and 6 months. RESULTS: A total of 130 lymphaticovenular drainage pathways were created in 39 "octopus" LVAs. All patients experienced prompt relief of lymphedema symptoms during the 1st postoperative week and continued to improve during the study period. None had postoperative complications. All had disease regression as demonstrated by statistically significant decrease in limb measurements (p = 0.0003) and severity down-staging. The modified technique was found to be easier than the standard supermicrosurgical technique and could be performed using a standard surgical microscope. CONCLUSION: The "octopus" technique is a viable, effective technical alternative to the standard LVA technique. It may greatly simplify this technically challenging procedure.

An old controversy revisited-one versus two venous anastomoses in microvascular head and neck reconstruction using anterolateral thigh flap.

BACKGROUND: The necessity of a second venous anastomosis in free tissue transfer is controversial. We review a single surgeon's 8-year experience of head and neck reconstruction using free anterolateral flap reconstruction to assess the need for a second venous anastomosis. PATIENTS AND METHOD: Three hundred and fifteen cases were included in the study after selecting only for anterolateral thigh flap, head, and neck reconstruction, and those that used superior thyroid artery as recipient. The selection criteria were designed to create as homogeneous a group as possible to decrease confounding factors. RESULTS: The group with single anastomosis required more frequent take-backs than the group with dual anastomoses (19% vs 10.8%, P = 0.055). The trend persisted when only take-backs for venous insufficiencies were compared (8.2% vs 2.5%, P = 0.039). When flaps with single anastomosis developed venous congestion, they were more likely to require operative salvage for venous insufficiency than those with dual anastomoses (35.5% vs. 6.3%, P = 0.037). No difference was found in postoperative complications and flap survival. CONCLUSION: Our data suggest that flaps with single venous anastomosis are more likely to require take-back for flap salvage than those with dual anastomoses.

International Microsurgery Club and World Society for Reconstructive Microsurgery Webinar: Career Building in Microsurgery.

Career building can be challenging for young surgeons, especially when topics such as lifestyle, work-life balance and subspecialization arise. Suggestions and advice from senior colleagues is very valuable but many young surgeons do not have such opportunities or are limited to a few senior surgeons. The International Microsurgery Club (IMC), in collaboration with the World Society of Reconstructive Microsurgery, organized a combined webinar for this topic and invited world renowned microsurgery masters polled by the IMC members to join, including Prof. Peter Neligan (Emeritus from University of Washington, United States), Prof. Raja Sabapathy (Ganga Hospital, India), Dr. Gregory Buncke (The Buncke Clinic, United States), Prof. Isao Koshima (Hiroshima University Hospital, Japan), Prof. David Chwei-Chin Chuang (Chang Gung Memorial Hospital, Taiwan), and Prof. Eric Santamaria (Hospital General Dr. Manuel Gea Gonzalez, Mexico) on May 1, 2022. Prof. Joon-Pio Hong (Asan Medical Center, South Korea) and Prof. Fu-Chan Wei (Chang Gung Memorial Hospital, Taiwan) were also selected but unfortunately could not make it and were therefore invited to another event in April 2023, summarized in a recently published paper. There is ample literature reporting on different aspects of developing a microsurgical career but the goal of this session was to offer an opportunity for direct exchange with experienced mentors. Moreover, insights from experienced microsurgeons from different part of the world were more likely to offer different perspectives on aspects such as career building, failure management, and team culture. This webinar event was moderated by Dr. Jung-Ju Huang (Taiwan), Dr. Susana Heredero (Spain), and Dr. Wei F. Chen (United States).

Current Concepts in Surgical Management of Lymphedema.

The decision on whom to offer surgical interventions for lymphedema requires collaboration and input from all involved specialists and should address patients' expectations, invasiveness of procedures, and disease severity. There is no consensus on what constitutes success or failure of complex decongestive therapy and when to pursue surgical intervention. Surgery has the potential to fundamentally affect the pathophysiology of the disease state and can be a powerful tool when used correctly. The dogma of which surgery to offer for a given clinical situation has been undergoing revision and is an area of ongoing research.

Penrose Drain Interposition - A Novel Approach to Preventing Adhesion Formation after Tenolysis.

Peritendinous adhesions represent a common problem without a satisfactory solution despite several studies. We have been using a conventional silicone Penrose drain in patients undergoing tenolysis in the hand since 2006. The Penrose drain is wrapped around the segment of the tendon after tenolysis. Therapy is started on the second post-operative day and the Penrose drain removed after one week in the outpatient clinic. We have had good outcomes with this technique. It is inexpensive, readily available and effective. Level of Evidence: Level V (Therapeutic).

Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts.

Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.

Trephination and subatmospheric pressure therapy in the management of extremity exposed bone.

BACKGROUND: Distal lower and upper extremity wounds with bone and tendon exposure present unique challenges to reconstructive surgeons. The limitations of the local anatomy usually make simpler reconstructive modalities such as primary closure and skin grafting difficult. As a result, wounds in this area, especially ones with bone or tendon exposures, are classically treated with free tissue transfer. METHODS: Limb preservation using the combination of bone trephination and subatmospheric pressure therapy is described. RESULTS: Six cases with preserved extremities are presented. Three cases illustrate extremity wound with bone and tendon exposure healing through pregrafting wound optimization (bone trephination) with the use of subatmospheric pressure therapy. CONCLUSIONS: This treatment may offer an alternative method of limb salvage, in cases where flaps or free tissue transfer are not possible or optimal.

Is the risk of lymphedema life-long following treatment for gynecologic cancer?-A case report.

Lymphedema is a common complication following oncologic surgeries and is classically described to occur months to a few years after these procedures. A 64 year-old woman with history of total abdominal hysterectomy and bilateral salpingo-oophorectomy developed right-sided lower extremity lymphedema 7 years after the surgeries. Lymphographic imaging performed approximately twenty years after the original surgeries revealed development of subclinical, asymptomatic lymphedema on the contralateral lower extremity. This delayed presentation of lymphedema after initial injury, is the first described case of subclinical lymphedema without detectable lymphatic injury, making it important to continuously monitor patients at risk for lymphedema long-term.

Multi-segment bioimpedance can assess patients with bilateral lymphedema.

BACKGROUND: Bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. There are two primary device modalities, through which BIS is used clinically: single-segment bioimpedance (SSB) and multi-segment bioimpedance (MSB), which differ in their mechanisms of gathering measurements. In this cross-sectional study, we study the difference between SSB and MSB in evaluating lymphedema by referencing the results with indocyanine Green (ICG) lymphography. METHODS: Patients with unilateral and bilateral lymphedema, presented to our department, were assessed with both SSB and MSB as part of a pre-lymphatic surgery evaluation between May 1, 2017, and November 31, 2017. Patients were imaged with ICG lymphography to confirm lymphedema presence. Standardized device measurement outputs from SSB and MSB were recorded and statistically analyzed. RESULTS: SSB was more sensitive (0.9) than MSB (0.75) for unilateral lymphedema. However, MSB had the added ability to assess patients with bilateral lymphedema with a sensitivity of 0.56 and specificity of 0.60. Furthermore, MSB had a stronger correlation with relative disease severity compared to SSB and quantified the differential extents of edema. In comparison, SSB provided a manipulated number, which was derived from a comparison of the abnormal to the normal limb. Medical staff reported MSB being easier to perform, and all patients reported the MSB measurement experience being more favorable. CONCLUSIONS: While both SSB and MSB provide diagnostic information on lymphedema, MSB is notably easier to perform, can detect bilateral disease states, and objectively quantifies limb fluid volume, allowing for disease tracking and assessment of surgical and rehabilitative treatment efficacy. On the basis of this study, our department has switched to universal MSB measurement.

Lymphedema Liposuction with Immediate Limb Contouring.

Liposuction is the treatment of choice for solid predominant extremity lymphedema. The classic lymphedema liposuction technique does not remove skin excess created following bulk removal. The skin excess is presumed to resolve with spontaneous skin contracture. We investigated the technique of simultaneously performing liposuction with immediate skin excision in patients with solid predominant lymphedema and compared the outcome with that from the classic technique. METHODS: Modified liposuction with skin excision (mLIPO) and standard liposuction without skin excision (sLIPO) were offered to patients with solid predominant extremity lymphedema. Skin traction of 4 cm and undulating skin mobility constituted positive "flying squirrel" sign. Patients with negative "flying squirrel" sign were excluded. mLIPO patients underwent skin excision. Surgical outcomes and postoperative complications were compared. RESULTS: The study enrolled 15 and 26 patients into the sLIPO and mLIPO groups, respectively. mLIPO patients demonstrated statistically significant decrease in seroma/hematoma, contour irregularity, and skin necrosis, while experiencing increased procedural satisfaction. CONCLUSIONS: Skin excision following liposuction for solid predominant lymphedema is safe. It decreases postoperative complication and improves surgical outcome.