Teaching of Microsurgery and Supermicrosurgery for Residents.

On the basis of our numerous years of experience in teaching residents without microsurgery experience and assisting in the initiation of microsurgery in clinical practice, we herein describe the general procedures and crucial aspects to consider regarding microsurgery and supermicrosurgery training for residents. The description focuses on training methods, surgical skills, and training time and effort. The target audience of the training is residents who have never performed microsurgery. We believe that any person, regardless of operative experience, can acquire the technique for microsurgery and supermicrosurgery by performing 4 to 5 hours of training per day over a total of 30 days within this program setting. Considering individual differences in learning and experience, the training can be completed in a shorter period by performing additional daily training. It is relatively simple for a well-trained microsurgeon to master the uncommon supermicrosurgery techniques. We hope that this report will help as many residents as possible in learning the art of (super)microsurgery.

Relationship Between Lymphaticovenular Anastomosis Outcomes and the Number and Types of Anastomoses.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is the first-line treatment for lymphedema in many hospitals. However, many aspects of its effects remain unclear. This study aimed to analyze problems with regard to the relationship between lymphaticovenular anastomosis and outcomes of surgery for lymphedema in the upper and lower extremities. METHODS: Eighteen articles were selected for review. The following information was extracted from these articles as factors associated with LVA for lymphedema in the upper and lower extremities: number of cases, average patient age, mean number of bypasses, lymphedema stage, duration and type of lymphedema, anastomotic technique, follow-up period, type of scale, and treatment outcomes. RESULTS: Upper extremity lymphedema: The average age of patients was 54.2 (range: 41.3-60.1) years. The mean number of anastomoses was 3.91 (range: 1.0-7.2). Six of nine articles provided data for volume change, and the mean volume change was 29% (-5%-50%). Lower extremity lymphedema: The average age of patients was 50.3 (range: 34-64 years). The mean number of anastomoses was 4.6 (range: 2.1-9.3). Comparison was difficult as different methods were used for postoperative evaluation (lower extremity lymphedema index in three patients, limb circumference in one, volume change in two, and restaging in three). CONCLUSIONS: We obtained useful information with regard to the effects of LVA in this review. An increased number of anastomoses between the lymphatic ducts and veins did not seem to improve the effectiveness of LVA. With regard to the stage of lymphedema, LVA may be useful for both early and advanced stages.

Stacked deep inferior epigastric perforator with sequential lumbar artery perforator flaps for bilateral breast reconstruction: A case report.

Breast size that can be reconstructed with a single flap is limited in thin patients who need bilateral autologous large-volume breast reconstruction. We present the case of a 39-year-old female with bilateral heterogeneous breast cancer. The patient underwent total mastectomy and radiation therapy on the left side and nipple sparing mastectomy on the right. We planned to use the stacked deep inferior epigastric perforator (DIEP) with sequential lumbar artery perforator (LAP) flaps because the patient's thigh was too thin and she refused using gluteal tissue. The flap was 10 cm wide at the abdomen, 5 cm wide at the waist, and 72 cm long overall. The DIEP and LAP flaps were harvested as one continuous flap and were folded onto each other to create a breast mound. The lumbar artery and vein were anastomosed to the distal stump of the deep inferior epigastric artery and vein (DIEA/V) intraflaps, and then, the proximal stump of the DIEA/V was anastomosed to the internal mammary artery and vein. The LAP flaps were placed deeply, whereas the DIEP flaps were placed superficially. Whole skin was de-epithelialized on the right side, and skin damaged by radiotherapy was released and replaced with abdominal skin on the left side. The flap survived fully, the shape of the reconstructed breasts was good, and the body line on the donor side was well maintained. We present the stacked DIEP with sequential LAP flaps as one of the options for bilateral breast reconstruction in thin patients with larger breast size.

Double-pedicle unaffected split-breast flap for unilateral breast reconstruction.

BACKGROUND: In some breast cancer patients with a contralateral unaffected hypertrophic and ptotic breast, autologous small-breast reconstruction with contralateral breast reduction is a good option. The current study is aimed to assess the efficacy of the double-pedicle unaffected split-breast (USB) flap harvested from the central half of the unaffected breast for unilateral breast reconstruction with contralateral transverse scar reduction mammoplasty. METHODS: Between February 2003 and May 2020, 14 patients underwent breast reconstruction using the USB flap. The mean patient age was 59.1 (range: 48-76) years, and the mean body mass index was 24.2 (range: 19.5-33.3) kg/m2 . This flap comprised half of the contralateral breast tissues with the 3rd or 4th internal mammary perforator (IMAP) and the lateral thoracic vessel (LTA/V). After USB flap elevation and LTA/V resection, flap perfusion from the IMAP was evaluated on indocyanine green (ICG) angiography. The medial pedicle USB flap was rotated 180° and was transferred to the affected site via the midline. The LTA/V was anastomosed to the recipient vessel to supercharge the distal part of the USB flap, which was then used for breast reconstruction. Then, the remaining contralateral upper and lower breast poles were used for transverse scar reduction mammoplasty. RESULTS: The mean flap size was 13.3 × 26.9 (range: 9.5 × 22 to 16 × 29) cm. All flaps and reduced breasts survived without serious complications such as flap necrosis, although there was one patient with hematoma and one patient with hypertrophic scar. ICG revealed poor perfusion in the distal, lateral part of the flap, ranging from 22.0% to 48.5% of the overall flap area. Final aesthetic evaluation was high, with 11 cases (78.6%) being "good" or "excellent" and 3 cases (21.4%) that were either poor or fair. The mean follow-up period for the patients was 53.8 (range: 15-84) months, with none of the patients presenting second primary breast cancer or recurrence in both breasts. CONCLUSION: USB flap breast reconstruction with contralateral reduction mammoplasty is a valuable option in breast cancer patients with a hypertrophic and ptotic breast.

Morphological Changes and Durability of Skin and Mucosal Flaps in Intraoral and Pharyngeal Reconstructions: Long-term Follow-up and Literature Review for Potential Second Carcinomas.

The long-term changes in tissues implanted in the oral cavity and pharynx after head and neck reconstruction have not been fully evaluated. This study aimed to clarify the morphological changes, long-term durability, and potential for secondary carcinogenesis in such tissues. In our single-center study, the rough morphological changes in 54 cases of intraoral and pharyngeal skin and mucosal flaps were evaluated more than 10 years after flap transfer. In addition, the literature on the development of second carcinomas from skin flaps was reviewed. The mean follow-up period for transferred flaps was 148 months. The reconstruction areas and the probability of morphological changes were significantly correlated (p=0.006), especially in cases with tongue, lower gingiva, and buccal mucosal reconstruction. Free jejunal flap surfaces were well maintained, whereas tubed skin flaps showed severe morphological changes in cases with pharyngeal reconstruction. None of the flaps in our series developed second primary carcinomas. Skin flaps generally had good durability for > 10 years in intraoral environments, while mucosal flaps had better durability for pharyngeal reconstruction. Second squamous carcinomas arising from skin flaps are extremely rare; however, surgeons should take this possibility into consideration and conduct meticulous and long-term follow-up.

Microsurgery for Head and Neck Reconstruction.

The most serious complication of free flap transfer is total flap necrosis, which is usually due to a microvascular problem. The development of a microsurgical instrument has greatly lowered the prevalence of postoperative vascular trouble to a rate of 1% to 3%. However, necrosis of the transferred flap in head and neck reconstruction can cause serious complications and postoperative functional deficiency. Therefore, for blood circulation disorder of the flap following free flap transfer, it is necessary to perform re-operation, as soon as possible, in order to attempt salvaging the flap after the disorder has been diagnosed.The goal of this study was to analyze the microsurgery for head and neck reconstruction. The author, with an experience of more than 500 microsurgical anastomoses, discusses microsurgery in head and neck reconstruction through the choices of recipient vessels, aspects that require attention in order to prevent vascular complications, and correspondence when complications occur.

Investigation of Free-Flap Transfer Reconstruction in Elderly Patients and Oral Intake Function.

The authors retrospectively examined 39 patients with head and neck reconstruction using a free-flap transfer with microsurgery in elderly patients aged over 80 years in our hospital. They investigated postoperative local complications, postoperative systemic complications, day of ambulation, the presence of delirium, the postoperative oral intake ratio, and the reconstructive method in mandibular reconstruction patients. There were 12 postoperative local complications. And postoperative systemic complications were detected in 19 patients; however, 17 of these were respiratory disorders due to pneumonia. There were 17 patients with postoperative delirium. Oral intake was resumed after an average of 14.9 days. Of these, 34 patients were eventually able to eat some kind of food. The incidence of local complications in elderly free-flap reconstruction patients was similar to that in young people. However, the rate of systemic complications was much higher in elderly patients. The authors suggest that free-flap reconstruction can be performed relatively safely in elderly people when a detailed preoperative surgical plan.

Salvage Surgery for Jejunal Necrosis After a Free Jejunal Transfer.

INTRODUCTION: Given the few reports regarding the salvage methods for managing jejunal necrosis, finding candidates for a meta-analysis or systematic review is difficult. Thus, this study aimed to describe the interventions for jejunal necrosis and investigate important points relating to this condition. METHODS: The interventions used to treat free jejunal necrosis are external fistula formation with jejunal debridement, secondary reconstruction of the local site, and overall status improvement, and re-free jejunal transfer with removal of the necrotic jejunum. Selecting the optimal procedure for each patient depends on the following factors. First, patients must have a good overall status to be able to endure re-free jejunal transfer, and next, the procedure is also dependent on local factors, including the intensity of the infections of the postoperative wound. RESULTS: One of the most common factors of jejunal necrosis is necrosis due to blood flow deficiency of the transferred tissue. However, among jejunal necrotic cases, some patients had no blood circulation disorder. We inferred that a non-occlusive mesenteric ischemia like occurred in the transferred jejunum, and also considered patients' overall status and necrotic association. Thus, patients who underwent re-free jejunal transfer are at an increased risk of experiencing re-necrosis. Based on these findings, we designed a jejunal necrosis algorithm. CONCLUSIONS: Early debridement and re-free jejunal transfer are optimal treatment options for patients with early-stage jejunal necrosis. Because re-jejunum transfer is a possible state after necrosis, it was thought that coping was the most important aspect of detection at an early stage.

A Detailed Examination of the Characteristics and Treatment in a Series of 33 Idiopathic Lymphedema Patients.

Background To date, only a few reports have been published on idiopathic lymphedema, and most of these are case reports. In this time, we performed a retrospective review of idiopathic lymphedema patients. Methods Forty patients presented with idiopathic lymphedema that was unrelated to surgery, injury, and medical conditions such as circulatory disease, kidney disease, and thrombotic venous disease. For these patients, we performed a retrospective review for edema-onset age, sex, location and stage of the edema, presence of cellulitis, episode related to edema onset, therapeutic intervention, and follow-up duration in the 33 patients whom we followed up. Results Among the 33 patients with idiopathic lymphedema, there were 11 patients with either congenital or childhood-onset lymphedema, 14 with adult-onset lymphedema, and the remaining 8 patients had an onset age of >60 years. Twenty of the 33 patients had undergone surgical treatment. Of the 19 patients who underwent lymphaticovenular anastomosis (LVA), 2 had good, 4 had fair, and 13 had poor treatment outcomes. Twelve patients successfully received only conservative treatment and follow-up for more than 3 months, without operation. The treatment outcome in these 12 patients was as follows: excellent in 4 patients, good in 6, and fair in 2 patients. Conclusion In this study, the usefulness of LVA for most patients with idiopathic lymphedema was not confirmed. Although this review did not include a conducted case, the indication for new surgical treatments such as vascularized lymph node transfer should be considered in the future.

Laser-Assisted Indocyanine Green Angiography Aids in the Reconstruction of Gustilo Grade IIIB Open Lower-Limb Fractures.

Background The treatment of trauma to the lower extremities often carries a high risk of complications. To the best of our knowledge, no study has been published regarding the treatment of open lower-limb fractures using laser-assisted indocyanine green angiography (LA-ICG). Here we retrospectively evaluated LA-ICG-based therapeutic interventions and reported the use of LA-ICG and its results in this application. Patients and Methods Between January 2011 and December 2015, a total of 23 cases with Gustilo grade IIIB open lower-limb fractures were investigated. LA-ICG was used to demonstrate the presence of necrotic tissue and determine the range of debridement. We compared 13 patients treated using LA-ICG from 2013 to 2015 with 10 patients treated without LA-ICG from 2010 to 2013. We reviewed tissue necrosis and other outcomes of these patients. Results The tissue necrosis rate in the LA-ICG-used group was significantly lower than that in the LA-ICG-free group. There were also significant differences in the average number of instances of tissue necrosis per patient, debridements, and deep-site infections. There was no flap loss. Conclusion By using LA-ICG, not only plastic surgeons but also clinicians in all associated departments including orthopedics can perform early reliable debridement and share in trauma treatment planning. We will continue to accumulate similar cases and hope to further improve LA-ICG techniques.

Relationship of the number and size of superficial groin lymph nodes with the stage of secondary lymphatic edema.

PURPOSE: This study evaluated the relationships of the size and number of superficial groin lymph nodes with the lower limb lymphedema stage and thus examined the role of superficial lymphatic lymph nodes in secondary lymphedema development. METHODS: We determined the number and size of superficial groin lymph nodes using horizontal plane computed tomography (CT) and the lymphedema stage in the lower limbs of 25 patients with gynecologic cancer. RESULTS: The patients had an average of 2.92 (range, 1-7) superficial groin lymph nodes; the mean size of the 146 evaluated lymph nodes was 7.55 mm (range, 5-15 mm). In 19 of 25 patients (76%), the side with major edema contained fewer superficial groin lymph nodes. In total, 22 patients (88%) had fewer superficial groin lymph nodes or a smaller total lymph node size on the edematous dominant side. CONCLUSIONS: In this evaluation of the link between superficial groin lymph node laterality and secondary lymphedema staging, we found that patients with large lymph node numbers and sizes tended to present with a relatively earlier stage of lymphedema. Our results therefore suggest that the size and number of superficial groin lymph nodes affect the lymphedema stage. J. Surg. Oncol. 2016;114:940-946. © 2016 Wiley Periodicals, Inc.

A Novel Lymphaticovenular Anastomosis Rat Model.

INTRODUCTION: Lymphaticovenular anastomosis (LVA) has become an important procedure for the surgical treatment of lymphedema. In the past, the anatomy of the lymphatic system of animal models has been reported. However, to our knowledge, there have been few reports of animal models of LVA including training model. In this study, we report on a relatively simple and ideal animal LVA model based on peritoneal lymph ducts and veins. PATIENTS AND METHODS: For 10 rats, diameters of lumbar lymphatic ducts and iliolumbar veins in the peritoneal cavity on both sides were measured, and LVA was performed. In addition, we measured the diameters of 28 lymphatic ducts and veins in 8 patients who had previously undergone LVA and compared the results with those obtained in this rat model. RESULTS: The mean diameter of the lymphatic ducts was 0.61 mm, and the iliolumbar veins were 0.81 mm. On the other hand, the mean diameters of the 28 lymphatic ducts and veins of the 8 patients in whom we performed LVA were 0.58 and 0.76 mm, respectively. The differences in the diameters of the lymph vessels and veins between the rats and patients were not statistically significant. CONCLUSIONS: We report on an LVA model involving the use of the lumbar lymphatic duct and iliolumbar veins of rats. The diameter, nature, and placement of the anastomosis using this model are very similar to that noted during real human surgery. We believe that our rat model will be useful as a practical training model for LVA and in studies on postoperative changes in LVA.

Iliolumbar Vein as a Training Model for Microsurgical End-to-Side Anastomosis.

Although a multitude of microsurgical training models have been reported, few experimental animal models are available for end-to-side anastomosis. In this study, the authors developed an end-to-side anastomosis rat training model that utilizes the iliolumbar vein and investigated its characteristics. Ten Wistar male rats were used as microvascular end-to-side anastomosis models. Diameters of the posterior vena cava and the root of the iliolumbar vein were measured on both sides. The mean diameter of the posterior vena cava was 5.40 mm (range, 3.2-3.6 mm). The mean diameter of the root of the iliolumbar vein was 1.12 mm (range, 1.1-1.4 mm). The mean duration of bilateral end-to-side anastomosis was 50.6 minutes (range, 48-55 minutes). The intraoperative patency rate after anastomosis was 100%. The authors described a rat training model for microsurgical end-to-side anastomosis. This model is especially useful because it closely simulates a real operation, and training can be performed relatively quickly.

Correction of the Lower Lip With a Cartilage Graft and Lip Resection in Patients With Facioscapulohumeral Muscular Dystrophy.

Facioscapulohumeral muscular dystrophy is an autosomal-dominant, slowly progressive myopathy that involves facial, shoulder, and upper arm muscles. Facial muscle atrophy and weakness leads to drooping of the lower lip, which has unfavorable functional and aesthetic outcomes. While there are several methods to correct drooping of the lower lip, including lip resection, free vascularized muscle transfer, and fascia suspension, there are no reports describing the use of an auricular cartilage graft to elevate the lip. The use of an auricular cartilage graft has several advantages, including a less invasive procedure and a longer-lasting effect. In this study, 3 patients with facioscapulohumeral muscular dystrophy underwent surgery involving an auricular cartilage graft with lip resection to sustain the lower lip, and satisfactory results were obtained. This procedure is simple and minimally invasive; thus, the authors believe that this is an appropriate technique to correct similar patients of lip deformity.

Analysis of 10-Year Training Results of Medical Students Using the Microvascular Research Center Training Program.

Background In this article, we reviewed the training results of medical students using the Microvascular Research Center Training Program (MRCP), and proposed an ideal microsurgical training program for all individuals by analyzing the training results of medical students who did not have any surgical experience. Methods As of 2015, a total of 29 medical students completed the MRCP. In the most recent 12 medical students, the number of trials performed for each training stage and the number of rats needed to complete the training were recorded. Additionally, we measured the operating time upon finishing stage 5 for the recent six medical students after it became a current program. Results The average operating time upon finishing stage 5 for the recent six medical students was 120 minutes ± 11 minutes (standard deviation [SD]). The average vascular anastomosis time (for the artery and vein) was 52 minutes ± 2 minutes (SD). For the most recent 12 medical students, there was a negative correlation between the number of trials performed in the non-rat stages (stages 1-3) and the number of rats used in the rat stages (stages 4-5). Conclusion Analysis of the training results of medical students suggests that performing microsurgery first on silicon tubes and chicken wings saves animals' lives later during the training program. We believe that any person can learn the technique of microsurgery by performing 7 to 8 hours of training per day over a period of 15 days within this program setting.

Head and neck reconstruction by using extended pectoralis major myocutaneous flap.

BACKGROUND: Pectoralis major flaps have been the workhorse in head and neck region reconstructions till date. However, pectoralis major flaps have disadvantages, including limitations regarding flap range and less stable blood flow than that in free flaps. Here, we report on the safe reconstruction to the oral cavity and neck area by using extended pectoralis major flaps. These flaps include both the normal vessels that feed pectoralis major flaps (the thoracoacromial artery and vein) and the lateral thoracic artery and vein to stabilize blood flow and expand flap survival area caudally. METHODS: Eight patients who had undergone reconstruction with extended pectoralis major flaps after the resection of head and neck cancers from June 2009 to March 2013. In all cases, the pectoralis major flap was elevated with a vascular pedicle comprising the thoracoacromial artery and vein and the lateral thoracic artery and vein. RESULTS: No blood circulation disorders, such as ischemia or congestion, were observed after the flaps were elevated and moved to the resected areas. All flaps were sutured on without difficulty. The area the flaps were harvested from was closed in a single stage. No postoperative complications such as hematoma, abscess, or fistula were observed. CONCLUSION: Extended pectoralis major flaps have a wide range and more stable blood flow, so they are thought to be useful in situations in which free flaps cannot be used for a variety of reasons.

Secondary head and neck reconstruction using free flap to improve the postoperative function or appearance of cancer survivors.

BACKGROUND: Secondary reconstructive operations are needed when patients with head and neck cancers have complications such as tumor recurrence after initial treatment. These reconstructive procedures are also performed to improve the function and appearance of the head and neck region for many cancer survivors. We reviewed the patients who underwent secondary head and neck reconstruction to improve function and appearance and considered the significance of this procedure for cancer survivors, as well as its associated problems. METHODS: Among the secondary reconstruction patients, 20 patients underwent reconstruction to improve their function and/or appearance. The goal of reconstruction for the patients was functional improvement in eight cases, appearance improvement in ten cases, and both function and appearance in two cases. Chi-square analyses were performed between the secondary and primary reconstructive groups with regard to the incidence of postoperative complications. RESULTS: All transferred flaps survived completely. We performed a small postoperative modification procedure in four cases. Minor complications not requiring surgical correction occurred in 2 of 20 patients. Additional operations were required owing to major postoperative complications in 2 of 20 patients. No significant associations were identified between the secondary and primary reconstructive groups with regard to postoperative complications. CONCLUSION: The outcomes of the present report suggest that secondary reconstructive surgery is a relatively safe procedure. The decision to perform adaptation operations depends on various factors after sufficient discussion with patients.

Minimally invasive multiple lymphaticovenular anastomosis at the ankle for the prevention of lower leg lymphedema.

BACKGROUND: The patients with secondary unilateral lower limb lymphedema are likely to experience lymphedema of the contralateral leg in the future. Our policy is to perform preventive lymphaticovenular anastomosis (LVA) of the contralateral limb without symptoms in these patients. In this report, we describe a minimally invasive preventive LVA procedure and present the preliminary results. METHODS: Ten patients with unilateral lower leg lymphedema underwent multiple LVA procedures through a skin incision over the ankle of the contralateral limb without symptoms. The Campisi clinical stage of these limbs without symptoms was stage 0 in five cases and stage 1A in five cases. The number of anastomoses performed through the incision over the ankle was two LVAs in five cases, three LVAs in four cases, and four LVAs in one case. RESULTS: All the multiple LVAs were completed without complications. The onset of postoperative cellulitis and edematous aggravation of the limb that received the minimally invasive preventive LVA procedure was not noted in any patient during 6-month follow-up period. CONCLUSIONS: This minimally invasive preventive LVA procedure might prevent lymphedema and improve the physical appearance of the limb with minimal scarring. Long-term follow-up will be necessary to monitor the future progression of edema in these patients.

Effects of radiation therapy on postoperative complications and adverse events in patients with head and neck reconstruction with flaps.

BACKGROUND: Radiation therapy is an essential treatment for head and neck cancer. However, the condition of the operative field is entirely altered after radiation therapy. This study aimed to examine the effects of preoperative radiation therapy on complications in patients who underwent head and neck reconstruction with flaps. METHODS: We retrospectively reviewed 252 instances of head and neck reconstruction with flaps in 240 patients between October 2000 and May 2011 at Okayama University Hospital. Of the participants, 51 had preoperative radiation exposure (21.3%) and 189 had no radiation exposure (78.7%). Postoperative complications were divided into three categories: minor complications that healed with conservative medical treatment within 4 weeks without a need for surgery; major complications requiring reoperation within 1 week after surgery (reoperation); and major complications needing additional operation later than 1 week after surgery (additional operation). RESULTS: Preoperative radiation therapy was only associated with major complications requiring reoperation later than 1 week after surgery (P < 0.001), open cervical wounds (P = 0.0030), and skin grafting for cervical skin necrosis (P = 0.0031) when compared to no radiation exposure. The results of flap failure were not significantly different between both groups (P = 0.3820). CONCLUSIONS: Minor complications and reoperation in the early postoperative period were not influenced by radiation exposure. The complications of radiation tend to be protracted and associated with additional operation later than 1 week after the initial surgery. It was thought that shortening of the duration of treatment was successful when we needed to perform early additional operations.

The drop-down technique as an optimal technique for back-wall end-to-side anastomosis.

An advantage of end-to-side anastomosis is that thrombogenesis in the anastomotic part is less likely than with end-to-end anastomosis. Conversely, the operative procedure for end-to-side anastomosis is more complicated than that of end-to-end anastomosis. We usually perform a modified back-wall technique in which the outflow vessel is dropped over the inflow vessel. We performed end-to-side anastomoses using the single-knot, back-wall, and drop-down techniques and compared the time required. In addition, the authors tried to perform microvascular anastomosis in 15 clinical cases using the drop-down technique. We were able to perform anastomoses quickly using the drop-down, back-wall, and single-knot techniques. The drop-down technique was possible in 12 cases of venous anastomosis in 15 head and neck reconstruction cases. Using this method, we can perform a continuous suture of the posterior wall easily and quickly. The drop-down technique can simplify continuous suturing of posterior wall in the same way as skin suturing.