Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis.

Swelling is the most common symptom of extremities lymphedema. Clinical evaluation and laboratory analysis were conducted after far infrared radiation (FIR) treatment on the main four components of lymphedema: fluid, fat, protein, and hyaluronan. Far infrared radiation is a kind of hyperthermia therapy with several and additional benefits as well as promoting microcirculation flow and improving collateral lymph circumfluence. Although FIR therapy has been applied for several years on thousands of lymphedema patients, there are still few studies that have reported the biological effects of FIR on lymphatic tissue. In this research, we investigate the effects of far infrared rays on the major components of lymphatic tissue. Then, we explore the effectiveness and safety of FIR as a promising treatment modality of lymphedema. A total of 32 patients affected by lymphedema in stage II and III were treated between January 2015 and January 2016 at our department. After therapy, a significant decrease of limb circumference measurements was noted and improving of quality of life was registered. Laboratory examination showed the treatment can also decrease the deposition of fluid, fat, hyaluronan, and protein, improving the swelling condition. We believe FIR treatment could be considered as both an alternative monotherapy and a useful adjunctive to the conservative or surgical lymphedema procedures. Furthermore, the real and significant biological effects of FIR represent possible future applications in wide range of the medical field.

Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema.

Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.

Supraclavicular osteocutaneous free flap: clinical application and surgical details for the reconstruction of composite defects of the nose.

The supraclavicular fasciocutaneous flap is a well-recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm × 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico-periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects.

Reconstruction after orbital exenteration using gracilis muscle free flap.

BACKGROUND: Orbital exenteration (OE) is a disfiguring procedure, which typically includes the removal of the entire eyeball including the globe, extraocular muscles, and periorbital soft tissues after malignancies excision or trauma. Several methods of orbital reconstruction have been attempted with varying success. In this report, we analyze results of the use of gracilis muscle free flap for reconstruction of OE defects and its feasibility for prosthetic rehabilitation. METHODS: Nine consecutive patients treated at the China Medical University Hospital of Taichung during January 2009 to January 2013, who had gracilis free flap reconstruction after OEs, were retrospectively reviewed. Cancer in six patients and trauma in remaining three patients was the cause for OE. RESULTS: Nine patients who underwent reconstruction with gracilis free tissue transfer had a successful outcome. There was not any donor or recipient site morbidity; however, one patient was deceased during follow-up period due to metastasis. The mean follow-up period was 23.5 months. Cosmetic results were acceptable both to patients and to surgeons. CONCLUSIONS: Gracilis free flap to repair OE defects may be a safe alternative for reconstruction. It provides a larger volume of well-vascularized tissue, greater placement flexibility, and minor donor site morbidity without any significant functional deficit.

Modified Charles procedure and lymph node flap transfer for advanced lower extremity lymphedema.

INTRODUCTION: Treatment of advanced lymphedema remains a challenge in reconstructive surgery. Microsurgical techniques seem to be effective in early stage lymphedema, however in advanced stages their role is not well established. In this study, we present a novel approach for advanced lymphedema combining excisional procedure (Charles) with transferring lymph node flap. PATIENTS AND METHOD: From 2010 to 2013, 24 patients (18 women, six men, mean age 53 years old) presented with late stage of lower extremity lymphedema. The modification of Charles procedure consisted of preserving the superficial venous system of the dorsum of the foot and the lesser saphenous vein, which were used for the venous anastomosis of the transferred lymph node flap. In 11 patients we transferred the inguinal lymph node flaps from the contralateral site, meanwhile in 13 patients supraclavicular lymph node flaps were used. RESULTS: Maximum reduction of the lymphedema was achieved. No major complication was detected postoperatively. There were two patients with partial loss of the skin graft necessitated re-grafting. All the lymph node flaps survived well. The patients resumed normal daily activities within a period of 2 months. The mean follow-up was 14 months (3-26 months). During this period, no recurrence of the lymphedema was observed. CONCLUSION: The combination of the modified Charles procedure with vascularized transferring of lymph node flap is an effective method for treatment of advanced stage lymphedema.

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP).

BACKGROUND: The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity. METHODS: Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function. RESULTS: Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity. CONCLUSIONS: For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.

Far infrared ray (FIR) therapy: An effective and oncological safe treatment modality for breast cancer related lymphedema.

BACKGROUND: The incidence of breast cancer related lymphedema is approximately 5%. Far infrared ray (FIR) treatment can potentially reduce fluid volume and extremity circumference as well as the frequency of dermato-lymphangitis (DLA). However, there is no published data on the oncological safety of FIR and the potential for activation of any residual breast cancer cells. The aim of this study is to investigate the safety of far infrared ray (FIR) treatment of postmastectomy lymphedema, clinically and in vitro. METHODS: Patients who underwent mastectomy more than 5years ago complicated by upper extremity lymphedema for more than 1year were included. The enrolled patients were divided into an FIR treatment group and a control group (conservative treatment using bandage compression). Outcome measures included tumor markers (CA153, CA125), ultrasonography of relevant structures and monitoring for adverse reactions 1year after treatment. For the in vitro part of the study, the effects of FIR on human breast adenocarcinoma cell lines (MCF7, MDA-MB231) compared to the effects of FIR on human dermal fibroblasts as a control were considered. The viability, proliferation, cell cycle and apoptotic statistics of the adenocarcinoma and human dermal fibroblast cell lines were analyzed and compared. RESULTS: Results demonstrated that after treatment with FIR, tumor marker (CA153, CA125) concentrations in both the FIR and control groups were not elevated. There was no statistically significant difference between FIR and control group marker expression (p>0.05). Furthermore, no patients were diagnosed with lymphadenectasis or newly enlarged lymph nodes in these two groups. Importantly, there were no adverse events in either group. The in vitro experiment indicated that FIR radiation does not affect viability, proliferation, cell cycle and apoptosis of fibroblasts, MCF-7 and MDA-MB-231 cells. CONCLUSIONS: FIR should be considered as feasible and safe for the treatment of breast cancer related lymphedema patients 5years after mastectomy. FIR does not promote recurrence or metastasis of breast cancer and is a well-tolerated therapy with no adverse reactions.

End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle.

BACKGROUND: Although perforator-to-perforator anastomosis in supermicrosurgery may be used in transferring free flaps with small vessels, it is still difficult in certain situations that include potentially infected wounds. Moreover, it is limited to smaller flaps. Anastomosis of large vessels is still safer for transfer of a large flap for most surgeons. The harvesting of a patch of the parent artery together with the perforator supplying the flap allows the surgeon to perform an anastomosis between the vessel ends of larger caliber, and possibly with greater anastomotic success. METHOD: When the vascular pedicle of a free flap is < 0.8 mm, an option is to take a cuff of the major artery for an end-to-patch anastomosis. From 1983 to 2013, this method was applied to the anteromedial thigh (AMT) flap (seven cases), the groin flap (81 cases), and the free Becker's flap (five cases). When a patch was taken from the femoral artery, direct anastomosis for the major artery was performed using 5/0 Prolene sutures, followed by coverage with local soft tissue. When a patch was taken from the ulnar artery, a patch of vein graft was used for repair of the ulnar artery. In one case, a segment of the femoral artery was harvested with an AMT flap and a segment of a sartorius muscle flap; the compound tissue was transferred to the neck with the femoral artery to replace the left carotid artery. In the donor site, the defect of the femoral artery was reconstructed with an artificial graft. RESULTS: The flaps had no failure or partial necrosis, but one patient developed bleeding from the femoral artery 2 days postoperatively. It was treated by adding one more suture for the femoral artery and coverage with the sartorius muscle. In the ulnar artery, the patients did not complain of cold intolerance and the postoperative angiogram showed good patency of the ulnar artery after an average follow-up of 1 year. CONCLUSION: For the majority of plastic surgeons, this method provides a reliable and comfortable anastomosis when transferring a flap with small vessels. The only concern is to repair the donor artery carefully and ensure coverage of the repair site with local tissue.

The first Smartphone application for microsurgery monitoring: SilpaRamanitor.

BACKGROUND: Postoperative monitoring of free flap tissue perfusion is vital. Devices available are expensive and complex to operate. Most surgeons rely on direct clinical observation. A monitoring system that is reliable, inexpensive, and easy to operate is needed. Using mobile phone technology, the authors developed and evaluated a new free flap monitoring system: SilpaRamanitor. METHODS: Software was developed for Android-operated mobile phones. Forty-two normal subjects were recruited to assess its effectiveness. Varying degrees of pressure were applied around the index finger to produce partial venous occlusion, partial arterial occlusion, complete venous occlusion, and complete arterial occlusion sequentially. Photographs of each subject's index and middle fingers were taken using the smartphone camera. To detect the abnormal perfusion presented on the index finger, the application was instructed to analyze photographs for color difference, with the unoccluded middle finger serving as the control. RESULTS: The sensitivity, specificity, accuracy, false-negative results, and false-positive results were 94, 98, 95, 6, and 1 percent, respectively. The accuracy of the application in grading occlusion severity was also evaluated. Thirty-nine cases (93 percent) were correctly identified as venous occlusion. The occlusion severity was correctly identified in 33 cases (85 percent). Likewise, for the 40 cases (95 percent) correctly identified as arterial occlusion, the method correctly categorized its severity in 33 cases (83 percent). CONCLUSIONS: The authors developed a new, accurate, and reliable diagnostic system for postoperative microsurgery monitoring using a smartphone application. SilpaRamanitor is inexpensive and easy to use, making it applicable in many microsurgical settings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Lymphedema fat graft: an ideal filler for facial rejuvenation.

Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.

Blood loss and transfusion rates in DIEP flap breast reconstruction. Introducing a new predictor.

BACKGROUND: The popularity of the DIEP flap has increased over the last decade. However, there is little information regarding the transfusion rates of this complex procedure. The current study reports the transfusion rates in patients who underwent DIEP flap reconstruction in our unit with an attempt to correlate significant blood loss with potential predictors such as the abdominal flap weight. METHODS-MATERIAL: A retrospective review of 131 patients who underwent DIEP reconstruction was performed. Patients' characteristics, risk factors, incidence of blood transfusions, Hb drop and complications were reviewed. For statistical analysis the two-tailed Student t-test, chi-squared significance test and multiple regression model were used. RESULTS: 12 patients (9.1%) were transfused compared to 80.3% and 18.8% described in the literature. Definite association was found between the presence of a complication and transfusion. No correlation was found between age, obesity, chemotherapy and/or radiotherapy or tamoxifen treatment and blood loss. However, operation duration, complications and weight all found to have significant correlation. On average, every additional hour of surgery adds 0.25 g of Hb drop; the presence of a complication adds 0.45 g of Hb drop, and every extra gram of tissue removed from the abdomen adds an extra 0.001 g of Hb drop. CONCLUSION: The different transfusion rates published reflect variations in surgical strategies, different operative technical details but mostly transfusion protocols applied in each unit. As a correlation with complications was found, it is quite important to identify predictors for significant blood loss to optimise the operation outcome which in our study are additional time of surgery, the presence of complication and increased flap weight.

Primary squamous cell carcinoma of the nipple: a diagnosis of suspicion.

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.

Absidia corymbifera fungal infection in burns: a case report and review of the literature.

Fungal infection in burn wounds can be difficult to diagnose and manage. A previously reported 10-year experience in burns patients confirms that although a marked decline has occurred in bacterial infection, fungal wound infection rates remain unaffected. Moreover, there is significant morbidity and mortality associated with fungal infections in patients with extensive burns. Absidia corymbifera is a saprophytic organism, with worldwide distribution, that is primarily isolated from soil as well as decaying vegetation and grass. It is an uncommon pathogen representing only 2 to 3% of all zygomycete infections in humans. The organism is opportunistic, rarely infecting the immunocompetent although such cases have been reported. To our knowledge, there are only two prior reports of A. corymbifera in burns patients. The ability to invade intact skin through proteolytic enzymes as well as the organism's angioinvasive propensity is associated with high mortality and demands a multidisciplinary approach. We present a case report of A. corymbifera infection in a burns patient and review the current literature.