Carotid artery and soft tissue reconstruction with superficial femoral artery-sartorius muscle-anteromedial thigh chimeric free flap: A case report and review of the literature.

Tumoral involvement of the carotid artery may require en-bloc resection in order to achieve a better regional control. Among the carotid reconstruction methods at disposal, autologous tissues appear to be more reliable in cases with high risk of infection and poor tissue healing like in radiated necks. We describe a case of a 55 year old man, who suffered from recurrent squamous cell carcinoma in the neck region, invading the common carotid artery. After en-bloc resection of the tumor together with skin, internal jugular vein, vagus nerve and common carotid artery, carotid reconstruction was performed with a flow-through chimeric flap based on superficial femoral vessels (15 cm). After resection of the tumor, the flap was used to replace the soft tissue defect (23 × 12 cm). Anteromedial thigh skin paddle (8 × 5 cm) and sartorius muscle (12 × 3 cm) were included in the flap. The superficial femoral vessels were reconstructed with 8-mm ringed polytetrafluoroethylene graft interposition. Thanks to an accurate surgical planning and a 2-team approach, the ischemia time of the leg was 42 min and there were no limb ischemia nor pathologic neurological signs after surgery. During the 12-month follow up, no other complication was registered. In our experience, microsurgical carotid reconstruction represents a reliable option with important advantages such as resistance to infection, optimal size matching, and good tissue healing between the irradiated carotid stump and the vascular graft.

The deep inferior epigastric lymphatic cable flap connected to gastroepiploic lymph node flap for treatment of refractory chylous ascites: Report of two cases.

Chylous ascites is the leakage of lipid-rich lymph into the peritoneal cavity usually due to disruption of lymphatics or increased peritoneal lymphatic pressure. Various surgical options have been proposed to treat chylous ascites but most have shown suboptimal outcomes. The gastroepiploic vascularized lymph node (GE-VLN) flap has been described previously for the treatment of lymphedema. In chylous ascites, this flap could provide an alternate drainage pathway for the intraperitoneal chylous fluid. The purpose of this report is to present another option for the microsurgical treatment of refractory chylous ascites. Herein, we report two patients with refractory chylous ascites secondary to cancer who have undergone deep inferior epigastric-based lymphatic "cable" flap (DIE-LCF) connected to a pedicle GE-VLN flap. Patients were followed-up for a minimum of 2 years. Within the first 3 months following surgery, the patient's nutritional parameters improved along with drastic reduction of ascites. At 2 years follow-up postoperative abdominal circumference decreased significantly. None required further peritoneal paracentesis and all patients were free of chylous ascites symptoms. In conclusion, the DIE-LCF connected to a pedicle GE-VLN flap could be a feasible option for the microsurgical treatment of refractory chylous ascites.

Combined microvascular breast and lymphatic reconstruction with deep inferior epigastric perforator flap and gastroepiploic vascularized lymph node transfer for postmastectomy lymphedema patients.

BACKGROUND: The combination of microvascular breast reconstruction (MBR) and vascularized lymph node transfer (VLNT) in a single-stage procedure is a surgical option for women who desire breast reconstruction and postmastectomy lymphedema surgery. In this study, we present a series of patients who underwent simultaneous lymphatic and MBR with the gastroepiploic VLNT (GE-VLNT) and the deep inferior epigastric perforator (DIEP) flap respectively. METHODS: Between 2018 and 2019, all consecutive patients diagnosed with lymphedema stage IIb-III International Society of Lymphology who opted to pursue simultaneous MBR with DIEP flap and GE-VLNT were included in this study. Patient demographics, comorbidities, prior radiation therapy, operative characteristics, surgical outcomes and complications were collected and analyzed. RESULTS: Six patients underwent simultaneous unilateral MBR with DIEP flap and GE-VLNT. The mean age was 48±10.5 years and mean body mass index was 28.2±4.5 kg/m2. The flap survival rate was 100%. One patient required re-exploration due to venous congestion of the lymph node flap but was successfully salvaged. There was no donor site morbidity at the donor or recipient site for the DIEP flap were seen. The mean circumference reduction rate was 30.0%±5.1% (P<0.001). One patient stage III underwent additional liposuction at 12 months postoperative to improve final results. CONCLUSIONS: The combined use of DIEP flap and GE-VLNT flaps in a single-stage procedure is a safe and reliable surgical option for patients with postmastectomy lymphedema who desire and are suitable for autologous microvascular breast and lymphatic reconstruction.

Single-stage VASER-assisted liposuction and lymphatico-venous anastomoses for the treatment of extremity lymphedema: a case series and systematic review of the literature.

BACKGROUND: A paradigm shift towards the use of combined physiological and excisional surgical approaches for the treatment of lymphedema is permeating the surgical practice worldwide. We describe a single-stage surgical approach combining-vaser assisted liposuction (VAL) and lymphatico-venous anastomoses (LVA) for the treatment of extremity-lymphedema. METHODS: Between March 2018 and March 2019, a retrospective review of patients with extremity-lymphedema stage IIb-III International Society of Lymphology who underwent the combined technique was done. Demographics, operative characteristics, clinical outcomes and complications were assessed. Additionally, a systematic review of studies that reported combined physiological procedures with liposuction for the treatment of lymphedema was conducted. RESULTS: A total of 24 patients [12 upper extremity lymphedema (UEL), and 12 lower extremity lymphedema (LEL)] were included and analyzed. The mean age was 54.5 years (38-72 years). The mean circumference reduction rate was 90% and 85% for UEL and LEL, respectively. Infection rate decreased to zero postoperatively in all patients. Ten studies were included in the review: six pooling 220 cases included two-stage procedures, and four pooling 66 cases described one-stage surgeries. All patients who underwent a combined approach reported clinical improvement. CONCLUSIONS: Our combined approach is safe surgical option and allows adequate limb size reduction with faster recovery in selected patients with lymphedema with strong fibroadipose component.

Comparisons in long-term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer.

BACKGROUND: Vascularized lymph node transfer (VLNT) is an emerging surgical treatment for lymphedema. However, literature-comparing outcomes of upper limb lymphedema (ULL) and lower limb lymphedema (LLL) is limited. Hence, the aim of this study is to compare the long-term clinical outcomes on ULL versus LLL in patients treated with VLNT. METHODS: A retrospective study retrieving data from patients with International Society of Lymphology (ISL) stages II-III who underwent different VLNTs from July 2010 to July 2016 in our institution was performed. Demographics preoperatively, and clinical data (limb circumference, infectious episodes, lymphoscintigraphic studies) preoperatively and postoperatively were recorded. Clinical outcomes by extremity were also analyzed. RESULTS: A total of 83 patients with lymphedema (ULL: n = 30, LLL: n = 53) were included. Mean follow-up time was 32.8 months (range 24-49 months). Mean circumference reduction was higher in patients with ULL compared to with LLL (28.6 ± 8.6 vs. 22.3 ± 10.1, p < .001), and for patients with secondary lymphedema (24.8 ± 9.6, p < .001) than for patients with primary lymphedema (18.9 ± 14, p > .05). Infectious episodes per year preoperative and postoperative showed that LLL patients had higher reduction on infection rate compared with ULL patients (2.4 ± 1.1 vs. 1.9 ± 1.2, p < .001). CONCLUSION: VLNT is a promising surgical treatment option for patients with lymphedema. This study suggests that VLNT may have a more beneficial outcome in patients with ULL and with secondary lymphedema.

Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review.

Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.

Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,' Homan's, and vascularized lymph node transfer (CHAHOVA) procedures.

BACKGROUND: End-stage lower extremity lymphedema (LEL) poses a particularly formidable challenge to surgeons as multiple pathological processes are at work. Because single modality treatment is often unsuccessful, we devised a comprehensive multimodal surgical treatment. The aim of this study is to share the technical considerations and examine the clinical outcomes of this combined approach. METHODS: Between 2013 and 2017, patients with International Society of Lymphology stage III, who underwent the combination treatment of Charles,' Homan's procedure with toe management and vascularized lymph node transfer (CHAHOVA), were included in this retrospective study. Outcomes evaluated were limb size, number of infectious episodes, compression garment usage, and rate of complications. RESULTS: A total of 68 patients were included. With a mean follow-up of 29 months, the overall circumference reduction rate for the upper thigh and the rest of the extremity was 67.4% (48.2-88.2%) and 98.1% (88-100%), respectively. During the follow-ups, 2 (2.9%) patients experienced episodes of cellulitis and the average number of yearly infections decreased from 4.2 to 1.2 episodes per person. All patients were able to discontinue compression therapy without recurrence of lymphedema. Nine (13.2%) patients reported minor complications. CONCLUSION: The combine CHAHOVA in a single-stage procedure is an effective and safe approach in the end-stage LEL.

Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema.

BACKGROUND: Treatment of advanced lymphedema requires not only restoration of physiological lymph drainage, but also excision of fibrotic tissue and excess skin. The aim of this study is to show how the combination of double vascularized lymph node transfers (VLNTs) and a modified radical reduction with preservation of perforators (RRPP) can accomplish both of these treatment goals. METHODS: Between 2010 and 2016, 16 patients (15 female and one male) with extremity lymphedema underwent a combined double gastroepiploic VLNTs and modified RRPP. Demographics, outcomes including circumference reduction rates, preoperative and postoperative lymphoscintigraphy, complications, and responses to the Lymphedema Quality of Life (LYMQOL) questionnaire were analyzed. RESULTS: All flaps survived. The mean follow-up period was 14.2 months (range, 12-19). The mean circumference reduction rate was 74.5% ± 6.9% for the upper limb and 68.0% ± 4.2% for the lower limb. There were no major complications. Minor complications, including numbness and hyperesthesia, were treated conservatively. LYMQOL showed a 2.7-fold quality-of-life improvement (P < 0.01). Postoperative lymphoscintigraphy showed improved lymphatic drainage in all cases. CONCLUSION: Combined double VLNTs and modified RRPP safely and effectively improves lymphatic drainage, reduces fibrotic tissue and excess skin, decreases episodes of infections, and improves patients' quality of life in the advanced stages of lymphedema.

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report.

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC-VLN) flap was used in the management of a 33-year-old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow-up, the IC-VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC-VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow-up are required to analyze the efficacy and long-term results of this flap.

Optimizing survival of large fibula osteocutaneous flaps for extensive full-thickness oromandibular defects: A two-stage approach with temporary orocutaneous fistula.

INTRODUCTION: Composite and large head and neck defects requiring extensive skin-mucosa coverage are often reconstructed by combining flaps. Herein, we present a simple and reliable two-stage fibula osteocutaneous (FOC) flap technique to improve the survival of a large skin paddle for oromandibular reconstructions. METHODS: From October 2011 to September 2016, 47 patients with through-and-through oromandibular defects were reconstructed using FOC flaps with large skin paddles. To ensure optimum survival of skin paddles, temporary orocutaneous fistula were left in place and closed during the second stage operation via de-epithelialization of the skin paddle and suturing of mucosa. Demographic data, operative details, and postoperative complications were recorded. RESULTS: The skin paddle dimensions ranged from 20 to 31.5 cm in length and 12 to 17 cm in width with an average area of 430.4 cm2 (range 300-504). The average time between the two stages and hospital stay were 10 days and 14 days, respectively. Complications at the donor site included wound dehiscence (n = 3, 6.4%), partial skin graft loss (n = 3, 6.4%) and hematoma (n = 2, 4.3%). Recipient site complications included two (4.3%) early postoperative venous congestions that resolved after elevation and three (6.4%) partial skin flap necrosis (less than 5% surface area). All complications resolved with bedside conservative management. There was only one take-back for evacuation of recipient site hematoma (2.1%) but no flap loss. CONCLUSION: Two-staged large skin paddle FOC flaps can simplify reconstruction of extensive oromandibular defects by improving the reliability of the sizable skin paddle and negating the need for a second flap.

Expanding the applications of the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for extensive defects.

BACKGROUND: The medial thigh is a well-hidden area. The two most common flaps from this area are the transverse upper gracilis (TUG) and profunda artery perforator (PAP) flaps. Herein, we explored the applications of combined TUGPAP flap to reconstruct large and complex defects in different regions. METHODS: Between November 2015 and May 2017, 28 patients who underwent reconstruction and extensive soft tissue coverage with the TUGPAP flap for the breasts, head and neck, and pelvi-perineal regions were included. The defects size ranged from 22 to 29 × 6-8 cm. All flaps were based on the two pedicles: the medial circumflex femoral artery for TUG flap and the profunda artery perforator for PAP flap. They were each anastomosed to a set of recipient vessels. A "Y"-shaped interposition vein graft (YVG) was used if only one recipient artery was available. RESULTS: The harvested skin paddle had dimensions ranged from 20 to 30 × 6-9 cm and all flaps survived completely. Postoperative complications included one case each of donor and recipient site seroma, and one case of wound dehiscence. They were all successfully managed conservatively. During an average follow-up period of 12.7 months, one patient reported permanent paresthesia in the donor site and another developed hypertrophic scar. All patients were able to resume daily activity without major concerns. CONCLUSION: The combined TUGPAP flap is a safe, effective, and a good alternative to the common workhorse flaps as it offers the potential for a large skin paddle and decent soft tissue volume with low donor site morbidity in a well-concealed area.

Staged inset of free flaps for complex microsurgical head and neck reconstruction to ensure total flap survival.

INTRODUCTION: Microsurgical reconstruction of complex head and neck defects often requires reliable tissue in multiple spatial configurations to achieve good functional and aesthetic outcomes. In addition to robust perforators, flap inset and wound closure require great caution to minimize complications especially in the presence of trismus with limited space for inset. This report describes the technique and results of our staged approach to flap inset which increases the chance of total flap survival in complex head and neck reconstructions. METHODS: From February 2010 to August 2016, a total of 53 patients were identified via a retrospective chart review. Patients who were suspected to have a high risk of vascular compromise and subsequently underwent complex head and neck reconstruction with staged inset of anterolateral thigh (ALT) flaps were included. The flap was inset only partially at the recipient site initially with fewer sutures. At a second stage, after neovascularization from surrounding tissue was established, the flap was partially elevated, divided and mobilized on its own pedicle for definitive inset. RESULTS: Fifty-one patients had complete survival of flaps and had uneventful postoperative course. Six cases required immediate re-exploration to release wound tension or reposition the pedicle. Of these, 4 flaps were salvaged, 2 failed due to small perforators despite anastomosis revision. The flap survival rate was 96.2% and the average time between 2 stages was 24 days (range, 21-28). CONCLUSION: Staged flap inset can improve free flap survival in complex head and neck reconstructions.

Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study.

BACKGROUND: Both physiologic and excisional procedures have been described for the treatment of lymphedema. However, there exist few reports that combine these procedures. The objective of this study was to evaluate the effectiveness of combining vascularized lymph node transfer (VLNT) with suction-assisted lipectomy (SAL) in a staged manner for the treatment of extremity lymphedema. METHODS: Patients with unilateral late stage II lymphedema (International Society of Lymphology), who consented to staged surgical treatment, were evaluated prospectively. Between 2014 and 2015, 12 female patients with upper (n = 6) or lower (n = 6) extremity lymphedema completed the treatment protocol. Primary outcomes evaluated included limb size and number of infectious episodes. In addition, compression garment usage was analyzed. RESULTS: The overall circumference reduction rate was on average 37.9% after VLNT and increased to 96.4% after SAL. While all patients had experienced at least one infectious episode prior to surgical treatment, only one patient did so after VLNT and none after SAL. All patients were able to eventually discontinue compression therapy. CONCLUSION: VLNT followed by SAL can allow patients with late Stage II lymphedema achieve near normal limb size and eradication of infectious episodes. At follow-up, these desirable outcomes were maintained well after discontinuation of compression therapy.