Closure of a free osteofasciocutaneous fibula flap donor site using local skin grafts or flaps: A systematic review and meta-analysis.

BACKGROUND: In free osteofasciocutaneous fibula flaps, secondary donor sites are avoided using one of three local closure methods: full-thickness skin grafts (FTSGs), split-thickness skin grafts (STSGs), or flaps. This systemic review aimed to evaluate the differences in outcomes among the three groups of closure methods used for free fibula flap defects. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the PubMed and Web of Science medical databases from inception to January 2021 for articles focused on closure of the free fibula flap donor site using the lower leg area-local skin graft or flap-that mentioned the free fibula flap defect size, and/or complications of the donor site. Study characteristics, free fibula flap size, and short-term complication rates were extracted for analysis. The pooled complication rates and confidence intervals were calculated based on the random-effects model. RESULTS: Eleven studies were included in the qualitative synthesis, and ten studies were included in the quantitative synthesis (meta-analysis). The FTSG (n = 79, 52.3%) was the most widely used method, while both STSG (n = 36, 23.8%) and flap (n = 36, 23.8%) were the least commonly used methods. The mean free fibula flap length and width were largest for the flap method (11.5 ± 2.5 cm and 6.0 ± 1.8 cm), and all closure methods were used for free fibula flap widths ≥3 cm. Rates of partial and complete necrosis were highest for the FTSG method (20.3%, p = .95, I2  = 0%) and lowest for the flap method (12.7%, p = .95, I2  = 0%). CONCLUSION: This systemic review indicated that any closure method could be adapted for a free fibula flap width ranging from 3 to 9 cm, and the flap method was associated with the lowest rate of short-term complications.

Salvage of Prosthetic Vascular Graft Infection in the Distal Thigh Using Free Latissimus Dorsi Musculocutaneous Flap: A Case Report.

BACKGROUND: Prosthetic vascular graft infection (PVGI) in the distal thigh is a rare wound; thus, little is known about which muscle flaps are the most useful and cause less lower extremity morbidity in such cases. Moreover, very few reliable muscle flaps are available around the distal thigh. CASE REPORT: We report the case of a 72-year-old woman suffering from a distal thigh wound with PVGI. The graft was successfully preserved after coverage with a free latissimus dorsi musculocutaneous (LDM) flap. CONCLUSIONS: The free LDM flap procedure is more challenging than local muscle flaps; however, a free LDM flap can be a feasible option for a distal thigh wound with PVGI with the advantage of the maintenance of walking capability by preserving the lower-limb muscles.

Combined Lymphovenous Anastomosis and Great Saphenous Vein Stripping for Comorbid Lymphedema and Varicose Veins.

Background: Treatment for patients with comorbid lymphedema and varicose veins is controversial. Surgical options for these patients are limited. The study was aimed to investigate the validity of combined lymphovenous anastomosis (LVA) and great saphenous vein stripping (GSVS) for comorbid lymphedema and varicose veins. Methods: Thirteen patients were involved in the study, and the detail was 21 edematous lower limbs (with coexisting varicose veins and lymphedema; the varicose vein and lymphedema [VL] group) who underwent combined GSVS and LVA therapy. Fifteen patients (with 30 edematous lower limbs and lymphedema only; the lymphedema [L] group) who underwent LVA only were included as a control group. GSVS was performed before LVA in the VL group. Results: No significant differences were seen between the groups at baseline. There were no cases indocyanine green (ICG) lymphography pattern deteriorated after GSVS. No significant difference was seen in lymphatic detection rate; 129.71% ± 58.27% (67%-333%) in the VL group and 122.27% ± 39.47% (50%-250%) in the L group (p = 0.59 > 0.05), respective lymphatic diameters 0.66 ± 0.13 (0.45-0.9) mm and 0.75 ± 0.17 (0.45-1.0) mm (p = 0.07 > 0.05), and respective lymphedema improvement rate 12.17% ± 7.35% (0%-27.4%) and 12.65% ± 7.43% (3.7%-22.3%) (p = 0.86 > 0.05). Discussion: In this study, stripping surgery does not cause lymphatic impairment, at least to the extent that would impede the success of an LVA procedure. Comorbid varicose veins and lymphedema can be treated surgically by a combination of LVA and GSVS.

Investigation of flow velocity in recipient perforator artery for a reliable indicator for the flap transfer with perforator to perforator anastomosis.

INTRODUCTION: In flap transfer with perforator to perforator anastomosis (FTPPA), encountering poor pulsation and blood flow in a recipient perforator intraoperatively often makes FTPPA impossible. This study sought to identify color and spectral Doppler ultrasonography (CSDUS) parameters that can aid reliable preoperative selection of a recipient perforator artery. PATIENTS AND METHODS: The study enrolled 38 patients with lower extremity lymphedema who underwent vascularized lymphatic tissue transfer with perforator to perforator anastomosis for physiological lymphatic flow reconstruction. In all cases, three candidate recipient perforators were searched in each lower extremities, and vessel diameter and peak systolic flow velocity (PSFV) were measured. The inclusion criteria for candidates were a vessel diameter of >0.5 mm and a PSFV of >10 cm/s. These measures were compared with intraoperative findings, diameters and if there was pulsation and visible spurting evident. RESULTS: A total of 114 candidates were selected, and 52 of the candidates were dissected until suitable perforators were found. PSFV (cm/s) on CSDUS was ≥20.0 in 32 perforators (84.2%) and was 15.0-19.9 in 6 perforators (15.8%) in the group with pulsation and visible spurting evident, and 15.0-19.9 in one perforator (7.1%) and ≤ 14.9 in 13 perforators (92.9%) in the group without pulsation and visible spurting evident. There was a statistically significant correlation between preoperative PSFV and intraoperative pulsation and visible spurting evident after dissection (P = 0.021 × 10-3 ). The flap survival rate was 92.1%. CONCLUSION: PSFV is an important preoperative determinant of the suitability of a recipient perforator artery for FTPPA.

Effectiveness of Flexor Tenotomy With a Transpositional Skin Flap for the Treatment of Severe Claw Toe Deformity With Mild-to-Moderate Joint Contracture.

Flexor tenotomy is the most effective for achieving healing and for the prevention of toe ulcer resulting from claw toe deformity. Although flexor tenotomy might be effective for a flexible claw toe, it might not provide benefits for severe claw toe deformity involving joint contracture. We devised a method involving the transfer of a flap to the skin defect caused by tenotomy, as severe claw toe deformity is associated with skin contracture. Although transpositional skin flap might increase the postoperative complication risks, it can be effectively used for severe claw toe deformity involving mild-to-moderate joint contracture.

Modified intraoperative distal compression method for lymphaticovenous anastomosis with high success and a low venous reflux rates.

INTRODUCTION: For successful lymphaticovenous anastomosis (LVA), it is important to create anastomoses with high flow to maintain patency. To ensure that this can be achieved, we compared the efficacy of a modified intraoperative distal compression (IDC) technique with the conventional no compression (NC) method for lower limb lymphedema. PATIENTS AND METHODS: In the IDC group, compression was applied to an area of the foot distal to the first LVA site. After completion of the first LVA, the distal compression was extended over the first LVA site to the distal end of the second LVA site. RESULTS: There was no significant difference between the IDC (n = 25) and NC (n = 25) groups in detection rate. However, significant differences were observed in lymphatic vessel diameter and LVA success rate. No intraoperative anastomotic obstruction was seen at the conclusion of surgery. Intraoperative congestion with blood was detected in lymphatic vessels in 8 of 79 anastomoses (10.1%) in the NC group, but not in any cases in the IDC group (p = 0.002). There was a significant between-group difference in the rate of improvement in lymphedema between the IDC (16.1±3.6) and NC groups (14.0±3.4; p = 0.03). DISCUSSION: IDC during LVA is thought to increase lymph flow in larger caliber lymphatics, leading to a high success rate and a low rate of venous reflux. IDC is beneficial when performing LVA.

The use of ipsilateral skin grafts or local flaps for the closure of a free radial forearm flap donor site: a systematic review.

Skin grafts from distant sites are typically used to close free radial forearm flap (FRFF) donor sites. However, a variety of closure methods have been reported that avoid a second donor site. These are divided into four groups: separately combined full-thickness skin graft (FTSG), FTSG method based on V-Y closure, perforator flap, and non-perforator flap. We aimed to assess the differences in outcomes, including adapted FRFF size and postoperative complications, among the four groups of closure methods used for FRFF defects. Applying the Preferred Reporting Items for the PRISMA protocol systematic reviews and meta-analysis, the PubMed and MEDLINE medical databases were searched from inception to September 2020 to identify articles about closure using an ipsilateral FTSG or local flap of the FRFF donor site. Study characteristics, FRFF size, complication rates were extracted for analysis. Twenty-four studies were included for analysis. The FTSG method based on V-Y closure was the most widely used and could be adapted to the largest and more variable FRFF sizes. The short-term complications rate was lowest for the FTSG method based on V-Y closure and the highest for the perforator flap method. The FTSG method based on V-Y closure was considered to be the most convenient and reliable. However, FRFF size should be restricted to ≤60 cm2, and the non-perforator flap can be a good choice if FRFF is <35 cm2.

Dual Purpose of De-Epithelialized Latissimus Dorsi Musculocutaneous Flap for Treatment of Chronic Frontal Sinusitis and Frontal Bone Defect.

ABSTRACT: Treating frontal sinusitis refractory to endoscopic sinus surgery and complicating frontal bone defect remains a challenge. One surgical option determined is free flap transfer, which has the versatility to accommodate adequate sinus obliteration and reconstruct skin and bone defects. After successful free flap transfer, forehead recessus deformity can emerge as an esthetic problem for patients waiting for cranioplasty. Hence, the authors examine three cases in which they performed free latissimus dorsi musculocutaneous (LDM) flaps for chronic frontal sinusitis with frontal bone defect. All LDM flaps survived without complications, and all patients achieved passable forehead contours without cranioplasty and with no occurrence of infection. In our procedure, the muscle portion of the LDM flap was used to obliterate the frontal sinus, which is similar to conventional free LDM flap. Conversely, our procedure also uses the de-epithelialized skin paddle of the LDM flap filled with the frontal bone defect, which is distinct from conventional free LDM flap. Thus, preventing postoperative forehead recessus deformity has been the identified as primary advantage of our procedure. The use of the free de-epithelialized LDM flap transfer fulfills two goals: controlling chronic frontal sinusitis and restoring a passable forehead contour.

Hybrid Treatment Combining Lymphaticovenous Anastomoses and the Oriental Herbal Medicine Bofutsushosan for Obesity-Associated Lower Leg Elephantiasis Nostras Verrucosa: A Case Report.

Elephantiasis nostras verrucosa (ENV) is a rare dermatological disease associated with chronic lymphedema caused by obesity, soft tissue infection, or chronic venous insufficiency. Although surgical debridement may be sufficient to treat the skin manifestations of ENV, treatment of ENV should focus on reducing lymph stasis to improve the skin changes and prevent recurrence. In this case report, we present the case of a 79-year-old woman who developed obesity-associated ENV in the lower leg. She was successfully treated by a combination of lymphaticovenous anastomoses and the oriental herbal medicine Bofutsushosan. To our knowledge, this is the first reported obesity-associated ENV case in which skin pathology was not only healed, but both edema relief and weight loss were successful. A treatment combining both surgery and the herbal medicine could be a potential therapeutic candidate for obesity-associated ENV.

Lymphovenous Anastomosis for Morbidly Obese Patients with Lymphedema.

Although patients with obesity-induced lymphedema can be treated by weight loss therapy, they find it difficult to lose the required amount of weight. The aims of this study were to clarify the characteristics of the lymphatic vessels in patients with obesity-induced lymphedema and to determine the feasibility and efficacy of lymphovenous anastomosis (LVA) in these patients. METHODS: Twenty-two patients (44 edematous lower limbs) with a body mass index (BMI) >35 kg/m2 (obese group) and 91 patients with lymphedema (141 edematous lower limbs) and BMI <25 kg/m2 were enrolled as a control group (nonobese group) and underwent LVA. The diameter and depth of lymphatics and the effect of LVA were compared. RESULTS: Lymphatics were detectable within 10-mm depth in the nonobese group and the obese group (3.0 ± 1.4 mm versus 3.5 ± 2.1 mm; P < 0.01). The lymphatic diameter was significantly greater in the obese group than in the nonobese group (0.79 ± 0.30 mm versus 0.54 ± 0.22 mm; P < 0.01). There was no significant difference in the rate of improvement in lymphedema after LVA between the nonobese group (9.1% ± 9.2%) and the obese group (8.9% ± 7.3%; P = 0.84). There was no correlation between the improvement rate of lymphedema and that of BMI in the obese group (P = 0.57). CONCLUSIONS: LVA is a feasible procedure even in morbidly obese patients. Considering that substantial weight loss is a difficult and time-consuming task for patients, LVA combined with not gaining weight is a good option for these patients.

A Simple, Versatile Device for Multiplanar Photography.

BACKGROUND: Taking pictures of protruding body parts (such as fingertips, toes, nipples, auricles, hands, and feet) from multiple directions is difficult. To solve this problem, we developed a simple and easy-to-use device, using mirrors. METHODS: The device is composed of 4 trapezoidal plane plastic mirrors firmly connected to each other. It is possible to photograph the object from 5 directions at once, including the real image of the object at the center, and 4 images that are reflected in the mirrors around the sides. RESULTS: The device allowed photographing various body parts from multiple directions at once. CONCLUSION: This simple and easy-to-use device helps us to take additional photographs in a single shot, which previously took more time and effort.

Lymphaticovenular anastomosis for recurrent cellulitis in a dementia patient with lymphedema.

We describe a dementia patient with comorbid recurrent cellulitis and lymphedema in the left lower limb who was treated successfully for recurrent cellulitis by lymphaticovenular anastomosis (LVA). The patient, an 83-year-old woman, suffered from recurrent cellulitis three times a year on average for 15 years. Compression therapy was impossible because of dementia. After LVA, there has been no recurrence of cellulitis for 2 years. It is difficult to administer decongestive lymphatic therapy in some patients, such as patients with dementia. LVA is a promising treatment for recurrent cellulitis in a dementia patient with lymphedema.

Gouty tophus without gout attacks treated using a reversed digital artery flap.

We report a rare case of a subcutaneous mass on the finger, which was suspected to be a soft tissue tumour and was reconstructed using a digital artery flap after excision biopsy. Tophaceous gout was pathologically diagnosed. The patient had no prior gouty attacks, making the preoperative diagnosis difficult.