How to Start and Build Microsurgery Practice-Topics on Success and Sustainability: Global/International.

Many young microsurgeons begin their careers at established hospitals where microsurgery resources are limited. This article shares the authors' experiences in overcoming challenges and establishing a microsurgery practice in a new hospital. Due to the lack of equipment, limited support from colleagues, absence of discussion partners, fear of failure, and unpredictable situations, many aspiring microsurgeons lose their motivation. The purpose of this article is to guide future microsurgeons by describing the author's actions and suggesting improvements for their first free flap case. Key factors for building a successful, sustainable, and enjoyable microsurgery practice include remembering your training and mentors, acquiring fundamental knowledge of microsurgery, creating a supportive ecosystem, and having fun.

The Quality of Life after Lymphaticovenous Anastomosis in 118 Lower Limb Lymphedema Patients.

Background This is a prospective study on 118 patients who underwent lymphaticovenous anastomosis (LVA) due to secondary lower limb lymphedema between January 2018 and October 2020 to evaluate patients' quality of life (QOL) using the Quality of Life Measure for Limb Lymphedema (LYMQoL) questionnaire. Methods The outcome measurement included the LYMQoL leg scoring system tool evaluating the function, appearance, symptom, mood, and overall outcome. In addition, correlation analysis was performed for three factors: based on International Society of Lymphology (ISL) stages, disease duration, and amount of volume reduction. Results The LYMQoL tool overall satisfaction score significantly increased at all intervals from 4.4 ± 0.2 preoperative to 6.5 ± 0.3 postoperative at 12 months ( p < 0.001). Significant findings were seen for each domain scores compared preoperatively and at 12 months: function score (18.6 ± 0.5 to 15.4 ± 0.6), appearance score (17.8 ± 0.5 to 16.0 ± 0.6), symptom score (11.8 ± 0.3 to 8.9 ± 0.4), and mood score (14.5 ± 0.4 to 11.4 ± 0.5; p < 0.05). The correlation analysis between improvement of the overall score and the ISL stage ( p = 0.610, correlation coefficient [ r ] = - 0.047), disease duration ( p = 0.659, r = - 0.041), and amount of limb volume reduction ( p = 0.454, r = - 0.070) showed no statistical significance. Conclusion The QOL of secondary lower limb lymphedema patients was significantly improved after LVA regardless of the severity of disease, duration of disease, and amount of volume reduction after LVA. Understanding the patient-reported outcome measurement will help the surgeons to manage and guide the expectations of the patients.

Septal Reposition During Intermediate Cleft Rhinoplasty: A Second Chance for Correcting Caudal Septal Deviation.

BACKGROUND: We investigated postoperative nasal morphology changes in patients undergoing secondary correction of cleft lip nose with septal repositioning and alar cartilage suspension during preschool age. METHODS: We performed a retrospective review on 77 patients who underwent secondary correction of cleft lip nose. The patients were aged 5‒6 years and underwent intermediate rhinoplasty by alar cartilage suspension, with or without septal repositioning. They were divided into two groups based on time: septal repositioning (Sep. 2015-Nov.2017) and control (Nov. 2009-Aug. 2015) groups. We performed a photogrammetric comparison by assessing the postoperative nasal morphology changes using linear and angular parameters. The cleft-to-non-cleft side ratio of each parameter was measured for the nostril width and height, nostril area, and caudal septal deviation angle. RESULTS: Among the 77 patients, 43 were selected as the septal repositioning group and 34 as the control. The evaluation timing was 5.32 ± 0.45-year-old for the preoperative period (T0), 6.57 ± 0.5-year-old for short-term (T1), and 9.28 ± 0.65-year-old for long-term follow-up (T2). The septal repositioning group showed significantly improved nostril width ratio and caudal septal deviation angle in the T1 and T2 periods. The septal repositioning significantly decreased the nostril area ratio in the T1 and T2 periods due to decreased cleft side and increased non-cleft side nostril area. CONCLUSIONS: The secondary correction of cleft lip nose with septal repositioning during preschool age offers a second chance to correct nasal appearance by balancing the nostril symmetry and correcting the caudal septal deviation.

Clinical Utility of Bioelectrical Impedance Analysis Parameters for Evaluating Patients with Lower Limb Lymphedema after Lymphovenous Anastomosis.

BACKGROUND: In lymphedema, lymphatic fluid accumulates in the interstitial space, and localized swelling appears. Lymphovenous anastomosis (LVA) is the most widely used surgery to rebuild a damaged lymphatic system; however, assessing outcome of LVA involves performing volume measurements, which provides limited information on body composition changes. Therefore, we analyzed the bioelectrical impedance analysis (BIA) parameters that can reflect the status of lymphedema patients who underwent LVA. METHODS: We retrospectively reviewed records of 42 patients with unilateral lower extremity lymphedema who had LVA. We measured the perioperative BIA parameters such as extracellular water (ECW) ratio and volume as defined by the percentage of excess volume (PEV). We evaluated the relationship between the amount of change in PEV and in BIA parameters before and after surgery. We confirmed the correlation between ΔPEV and BIA parameters using Spearman's correlation. RESULTS: Most patients included had secondary lymphedema due to cancer. Average age was 51.76 years and average body mass index was 23.27. PEV and all BIA parameters after surgery showed a significant difference (p < 0.01) compared with preoperative measurements. The ECW ratio aff/unaff showed the strongest correlation with PEV with a correlation coefficient of 0.473 (p < 0.01). CONCLUSION: Our findings suggest that BIA parameters, especially ECW ratio aff/unaff could reflect the status of patients with lower limb lymphedema after LVA. Appropriate use of BIA parameters may be useful in the postoperative surveillance of patients.

Planes for Perforator/Skin Flap Elevation-Definition, Classification, and Techniques.

BACKGROUND: Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue. METHODS: This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation. RESULTS: Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy. CONCLUSION: These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

Comparative Analysis between Side-to-End and End-to-End Lymphaticovenous Anastomosis for Secondary Lower Limb Lymphedema.

BACKGROUND: The purpose of this retrospective study was to describe, evaluate, and compare the outcome between end-to-end and side-to-end lymphaticovenous anastomoses for all stages of lymphedema. METHODS: A total of 123 patients were divided into the end-to-end ( n = 63) or the side-to-end ( n = 60) group. The demographics and intraoperative and postoperative findings were evaluated. In addition, subcategory evaluation was performed for early- and advanced-phase lymphedema. RESULTS: The demographic findings were insignificant. The intraoperative findings showed a significantly higher number of lymphaticovenous anastomoses performed for the end-to-end group (4.1 ± 1.7) over the side-to-end group (3.2 ± 1.2) ( p < 0.001), whereas the number of different lymphatic vessels used per patient was not significant (3.4 ± 1.4 versus 3.2 ± 1.2; p = 0.386). The diameter of the lymphatic vessels was not significant (0.43 ± 0.06 mm versus 0.45 ± 0.09 mm; p = 0.136). Although both groups showed significant postoperative volume reduction, the side-to-end group had a significantly better reduction in all time intervals ( p < 0.03) and longitudinal outcome ( p = 0.004). However, the subcategory evaluation for early-phase patients showed no difference between the two groups, but a significantly better volume reduction ratio was noted for the side-to-end group at all time intervals ( p < 0.025) in addition to overall longitudinal outcome ( p = 0.004) in advanced lymphedema patients. CONCLUSIONS: This is the first study to report the efficacy of end-to-end versus side-to-end lymphaticovenous anastomosis in different phases of lymphedema. Although both end-to-end and side-to-end lymphaticovenous anastomoses are significantly effective in volume reduction, there was a significantly better reduction for the side-to-end group in advanced-phase lymphedema patients with stage II late and stage III disease, whereas no difference was noted for early-phase lymphedema patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Retrospective Case Series on Free Flap Reconstruction for Ischemic Diabetic Foot: The Nutrient Flap Further Explained.

BACKGROUND: This retrospective case series compares the outcomes and postoperative oxygen levels in patients who underwent free flap versus primary closure/local flap reconstruction for ischemic diabetic foot wounds to determine the influence of free flap on the surrounding ischemic tissues. The authors hypothesized that the free flap would benefit the surrounding ischemic tissue as a nutrient flap by increasing the tissue oxygen content. METHODS: The patients were divided into two groups: group 1 underwent free flap reconstruction, and group 2 underwent partial foot amputation with primary closure/local flap. Patient demographics, endovascular intervention, surgical outcome, postreconstruction intervention, and prereconstruction and postreconstruction transcutaneous oximetry were analyzed. RESULTS: Among 54 patients, 36 were in group 1 and 18 were in group 2. There were no differences in patient demographics between the two groups. All patients had successful angioplasty. Statistical significance was noted in postreconstruction intervention in which group 2 required 2.8 ± 2.9 débridements (versus 1.2 ± 2.5 for group 1) and seven of 18 below-knee amputations (versus three of 36 for group 1) (p < 0.05). Transcutaneous partial pressure of oxygen levels were significantly higher in group 1 at 6 months after reconstruction (61.6 ± 7.5 versus 32.6 ± 5.8 mmHg) (p < 0.01). CONCLUSION: This study shows that the role of the free flap in ischemic diabetic limb may expand beyond that of providing coverage over the vital structures, and it supports the use of the free flap as a nutrient to increase oxygen content in the ischemic diabetic foot. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Are Perforators Reliable as Recipient Arteries in Lower Extremity Reconstruction? Analysis of 423 Free Perforator Flaps.

BACKGROUND: Perforator flaps have revolutionized lower limb reconstruction by offering single-stage thin, pliable coverage with an excellent aesthetic match. Although anastomosis of the flap to a major artery remains the gold standard, perforator-to-perforator anastomosis has several advantages, including expedient recipient dissection and increased recipient options in vessel-depleted extremities. The aim of this study was to compare flap survival when a perforator or major artery was used as a recipient vessel. METHODS: A retrospective cohort of free perforator flaps for lower limb reconstruction was reviewed. Demographics, comorbidities, vascular status, defect characteristics, operative details, and complications were recorded. Outcomes for perforator and major artery recipients were compared. RESULTS: Four hundred twenty-three flaps were performed for various reasons using perforator flaps. The total limb salvage rate was 98.8 percent. Total and partial flap failure rates were 6.1 percent and 9.0 percent, respectively. Comparing perforator recipients [n = 109 (25.8 percent)] to major artery recipients [n = 314 (74.2 percent)], there was no significant difference in total (p = 0.746) or partial flap failure (p = 0.212). Significant factors between the groups included larger flap size with major artery recipients (p = 0.001) and shorter operative time when using a perforator recipient (p = 0.012). CONCLUSIONS: Perforator-to-perforator anastomosis is a reliable option that affords equivalent rates of flap success compared to major artery anastomosis in lower extremity reconstruction. The authors advocate using a major artery recipient in defects where the axial vessels are easily accessible. A perforator recipient is a viable alternative in defects where access to the axial vessels is inconvenient and in patients with limited recipient options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Clinical Applications of Augmented Reality Technology in Microsurgical Planning of Head and Neck Reconstruction.

BACKGROUND: To perform head and neck reconstruction, the exact location of recipient vessels must be evaluated preoperatively. This study aimed to superimpose arterial and venous pathways identified by computed tomography angiography (CTA) on patients using augmented reality (AR) techniques to freely select recipient vessels. METHODS: Patients who underwent reconstructive microsurgery due to defects on the scalp, forehead, and glabella from July 2019 to October 2019 were enrolled. The superficial temporal artery (STA) and superficial temporal vein (STV) were marked using hand-held Doppler. Furthermore, the three-dimensional reconstructed CTA image was superimposed on the patient's face using a smartphone application, Camera-Lucida, and marked. The accuracy of mapping was evaluated intraoperatively. Success rates and the time consumed for mapping were compared. RESULTS: Twelve patients underwent preoperative marking. Success rates of STA mapping using the AR technology and hand-held Doppler were 100% and 83%, respectively (P = 0.48). The mean time consumed for STA marking was 90.2 ±â€Š17.7 seconds and 121.0 ±â€Š117.7 seconds, respectively (P  = 0.75). The success rate of STY marking with the AR technology was superior to that with hand-held Doppler (100% versus 58.3%; P = 0.037). STY marking was faster with the AR technology than with hand-held Doppler (mean time, 91.2 ±â€Š25.7 seconds versus 94.5 ±â€Š101.6 seconds; P = 0.007). CONCLUSIONS: The AR technology could be the paradigm shift in the field of microsurgical reconstruction. it can connect threedimensional CTA data with patient topography, leading to not only more precise operations but also improved outcomes in patients undergoing microsurgical reconstruction.

Epidural Anesthesia and Arterial Maximal Flow Velocity of Free Flap in Patients Having Microvascular Lower Extremity Reconstruction: A Randomized Controlled Trial.

BACKGROUND: One of the critical factors for free flap survival is to maintain adequate perfusion. The authors evaluated the effect of epidural anesthesia on arterial maximal flow velocity of the free flap in microvascular lower extremity reconstruction. METHODS: This is a prospective randomized study where patients were allocated to receive either combined general-epidural anesthesia (epidural group, n = 26) or general anesthesia alone (control group, n = 26). After injecting epidural ropivacaine 10 ml in the epidural group, the effect on arterial maximal flow velocity of the free flap was analyzed using ultrasonography. The primary outcome measurement was the arterial maximal flow velocity 30 minutes after establishing the baseline. Intraoperative hemodynamics and postoperative outcomes such as postoperative pain, opioid requirements, surgical complications, intensive care unit admission, and hospital length of stay were also assessed. RESULTS: The arterial maximal flow velocity 30 minutes after the baseline measurement was significantly higher in the epidural group (35.3 ± 13.9 cm/second versus 23.5 ± 8.4 cm/second; p = 0.001). The pain score at 1 hour postoperatively and opioid requirements at 1 and 6 hours postoperatively were significantly lower in the epidural group [3.0 (interquartile range, 2.0 to 5.0) versus 5.0 (interquartile range, 3.0 to 6.0), p = 0.019; 0.0 µg (interquartile range, 0.0 to 50.0 µg) versus 50.0 µg (interquartile range, 0.0 to 100.0 µg), p = 0.005; and 46.9 µg (interquartile range, 0.0 to 66.5 µg) versus 96.9 µg (interquartile range, 41.7 to 100.0 µg), p = 0.014, respectively]. There were no significant differences in intraoperative hemodynamics or other postoperative outcomes between the two groups. CONCLUSION: Epidural anesthesia increased the arterial maximal flow velocity of the free flap and decreased postoperative pain and opioid requirements in microvascular lower extremity reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Long Pedicled Superficial Circumflex Iliac Artery Flap Based on a Medial Superficial Branch.

BACKGROUND: A superficial circumflex iliac artery perforator flap has several advantages, such as reduced thickness, minimal donor-site morbidity, and inconspicuous scar. However, the application of a superficial circumflex iliac artery perforator flap is restricted because of its limited pedicle length. The aim of this article was to outline the technical modifications of superficial circumflex iliac artery perforator flap elevation to obtain long pedicles. METHODS: This is a prospective study of 31 consecutive patients who required a long pedicled superficial circumflex iliac artery perforator flap between September of 2016 and December of 2019 at the authors' center. According to a preoperatively marked pathway of the superficial branch of the superficial circumflex iliac artery, the superficial circumflex iliac artery perforator flap was designed. During the elevation, the design was modified according to the perforator location in the free-style technique. The characteristics of the patients and the flaps, including pedicle length, were recorded. The revision rate, complication rate, and need for a secondary procedure were analyzed. RESULTS: The mean follow-up period was 563 days (range, 92 to 1383 days). The mean length of the pedicle obtained was 6.9 cm (range, 6 to 8 cm) from the point where the pedicle merges into the flap. Long pedicles were anastomosed to the main source vessel or branch without tension. No major complications were reported. CONCLUSIONS: Overcoming the short pedicle length of a superficial circumflex iliac artery perforator flap by designing the flap laterally and performing an intraflap dissection is a reliable option when a longer pedicle is required, irrespective of the specific anatomy of the superficial circumflex iliac artery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Patient-specific surgical options for breast cancer-related lymphedema: technical tips.

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient's pathology, the treatment plan should be carefully decided and individualized. At the authors' institution, the treatment plan is made individually based on each patient's symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient's pathophysiology, optimal outcomes can be achieved. Depending on each patient's pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

Effects of Botulinum Toxin A on an Incisional Hernia Reconstruction in a Rat Model.

BACKGROUND: Although the effects of botulinum toxin A on hernia reconstruction have been consistently reported, few studies provide objective evidence. The authors aimed to compare the effects of chemical component separation with those of mechanical component separation, and with a combination of chemical and mechanical component separation, in a rat hernia model. METHODS: Rats were divided into four groups: 1, control; 2, chemical component separation; 3, mechanical component separation; and 4, chemical and mechanical component separation. Four weeks after hernia induction, botulinum toxin A was injected into groups 2 and 4. Hernia repair was performed 2 weeks after chemical component separation when mechanical component separation was performed in groups 3 and 4. Pretreatment and posttreatment defect sizes, traction forces, intraabdominal pressure, and hernia recurrences were analyzed. RESULTS: The defect size was significantly decreased in groups 2 and 4 after chemical component separation. The traction force was significantly smaller in groups 2 and 3 compared with the control group, and the effects of chemical and mechanical component separation were additive. The mean intraabdominal pressure was 16.83 mmHg in group 1, 10.67 mmHg in group 2, 10.17 mmHg in group 3, and 9.67 mmHg in group 4, thus showing significant reductions following chemical and mechanical component separation. Recurrence was observed in all six animals (100 percent) in groups 1 and 3, but in only one of six (17 percent) in groups 2 and 4. CONCLUSIONS: Preoperative botulinum toxin A significantly reduces hernia size (by 30 percent) and the traction force required to medialize the rectus abdominis. After hernia repair, chemical component separation decreases the intraabdominal pressure to a similar degree as mechanical component separation, but only chemical component separation appears to reduce hernia recurrence.

Free Tissue Transfer after Open Transmetatarsal Amputation in Diabetic Patients.

BACKGROUND: Transmetatarsal amputation (TMA) preserves functional gait while avoiding the need for prosthesis. However, when primary closure is not possible after amputation, higher level amputation is recommended. We hypothesize that reconstruction of the amputation stump using free tissue transfer when closure is not possible can achieve similar benefits as primarily closed TMAs. METHODS: Twenty-eight TMAs with free flap reconstruction were retrospectively reviewed in 27 diabetic patients with a median age of 61.5 years from 2004 to 2018. The primary outcome was limb salvage rate, with additional evaluation of flap survival, ambulatory status, time until ambulation, and further amputation rate. In addition, subgroup analysis was performed based on the microanastomosis type. RESULTS: Flap survival was 93% (26 of 28 flaps) and limb salvage rate of 93% (25 of 27 limbs) was achieved. One patient underwent a second free flap reconstruction. In the two failed cases, higher level amputation was required. Thirteen flaps had partial loss or other complications which were salvaged with secondary intension or skin grafts. Median time until ambulation was 14 days following reconstruction (range: 9-20 days). Patients were followed-up for a median of 344 days (range: 142-594 days). Also, 88% of patients reported good ambulatory function, with a median ambulation score of 4 out of 5 at follow-up. There was no significant difference between the subgroups based on the microanastomosis type. CONCLUSION: TMA with free flap reconstruction is an effective method for diabetic limb salvage, yielding good functional outcomes and healing results.

Lymph Node to Vein Anastomosis (LNVA) for lower extremity lymphedema.

The microsurgical options for lower limb lymphedema is a challenge. In search to improve the overall result, we hypothesized it would be beneficial to add the functioning lymph nodes to vein anastomosis (LNVA) in addition to lymphovenous anastomosis (LVA). This is a retrospective study of 160 unilateral stage II & III lower extremity lymphedema comparing the outcome between the LNVA + LVA group and the LVA only group from May 2013 to June 2018. MRI was used to identify the functioning lymph nodes. Patient outcome, including lower extremity circumference, body weight, bio impedance test, and other data were analyzed to evaluate whether lymph nodes to vein anastomosis (LNVA) improved outcome. The LNVA + LVA group showed significantly better results for circumference reduction rate, body weight reduction rate, and extracellular fluid reduction rate of the affected limb as compared to the LVA only group for both stage II and III lymphedema. The MRI imaging revealed that 9 cases had no identifiable lymph nodes of the affected limb and 54 cases with a nonfunctioning lymph node upon exploration despite positive imaging. Correlation showed the lymph node size needed to be at least 8 mm in the MRI to be functional. The LNVA + LVA approach for lymphedema has the benefit of better reduction as compared to LVA alone in the lower limb as well as the suprapubic region. Preoperative MRI will help to identify the functioning lymph node by increasing the overall probability of positive outcome.

Who Will Continuously Depend on Compression to Control Persistent or Progressive Breast Cancer-Related Lymphedema Despite 2 Years of Conservative Care?

BACKGROUND: When a patient with breast cancer-related lymphedema (BCRL) depends on continuous compression management, that is, when interstitial fluid accumulation is continuously ongoing, surgical treatment should be considered. Physiologic surgery is considered more effective for early-stage lymphedema. The purpose of this study was to identify predictors of patients with BCRL who will be compression-dependent despite 2 years of conservative care. METHODS: This study included patients with BCRL who followed up for 2 years. Patients were classified into two groups (compression-dependent vs. compression-free). We identified the proportion of compression-dependent patients and predictors of compression dependence. RESULTS: Among 208 patients, 125 (60.1%) were classified into the compression-dependent group. Compression dependence was higher in patients with direct radiotherapy to the lymph nodes (LNs), those with five or more LNs resections, and those with BCRL occurring at least 1 year after surgery. CONCLUSIONS: BCRL patients with direct radiotherapy to the LNs, extensive LN dissection, and delayed onset may be compression-dependent despite 2 years of conservative care. Initially moderate to severe BCRL and a history of cellulitis also seem to be strongly associated with compression dependence. Our results allow for the early prediction of compression-dependent patients who should be considered for physiologic surgery.

The Role of Duplex Ultrasound in Microsurgical Reconstruction: Review and Technical Considerations.

BACKGROUND: With the technological advances, microsurgery has evolved to the era of supermicrosurgery since its inception. With the popularization of these flaps, proficiency in using tools such as color Doppler ultrasound (CDU) has become crucial. Despite the increased interest, studies regarding the role of ultrasound in microsurgical reconstruction are scarce. Therefore, in this study, we discussed currently available imaging modalities for reconstructive surgeons, types of ultrasound, and the role of ultrasound in microsurgical reconstruction, and made recommendations for ultrasound use in reconstructive surgery. METHODS: We performed a computerized search of ultrasound in reconstructive surgery using the MEDLINE database. Data regarding ultrasound indications, usage, and outcomes were collected. RESULTS: Of the 115 articles identified, the majority was written on nonreconstructive ultrasound uses (51.4%). For the reconstructive uses, mapping of perforators was the most common usage (39.1%), followed by flap monitoring and volume measurement. In addition, we found that there are a limited number of literature on the role of CDU in reconstructive surgery, especially on its intraoperative and postoperative use. CONCLUSION: CDU is a valuable and powerful tool for any reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. As the demand of customized flaps using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery increases, understanding and becoming versatile in CDU will be critical. We hope our experience with using ultrasound and refinements that we made are helpful for those who would like to include it as a part of their armamentarium.

Shaping an Anatomical Breast Using Extended Latissimus Dorsi Flap and Lipofilling in Immediate Breast Reconstruction.

BACKGROUND: Although many attempts have been made to augment the volume of the latissimus dorsi (LD) myocutaneous flap in breast reconstruction, only a few studies on the shaping of the LD flap to achieve a natural native breast have been conducted. We introduce our novel method to reconstruct a naturally shaped breast by combining an extended LD myocutaneous flap with immediate lipofilling. METHODS: The patients who underwent an immediate unilateral breast reconstruction with an extended LD myocutaneous flap and lipofilling were retrospectively reviewed. The extended LD myocutaneous flap in 180-degree rotation was combined with an immediate lipofilling procedure followed by suturing to reproduce the constant dimensions of a neobreast. RESULTS: A total of 45 patients with a mean age of 46 years and an average body mass index of 23.1 kg/m were enrolled. The average weight of the mastectomy specimens was 299.0 g. An average 18.8 × 8.7-cm skin paddle within the flap was harvested, and 71.0 mL of fat was injected into the flap. Donor site seroma was found in 9 patients, and no flap or fat necrosis was found. CONCLUSIONS: Our technique of extended LD muscle flap with lipofilling reproduced breasts with constant dimensions and appropriate width, height, and projection. Shaping the LD muscle flap is not difficult or unpredictable. This is a simple and easy technique to shape the LD flap and will provide surgeons with an additional autologous option for breast reconstruction.

Safety of Retrograde Flow of Internal Mammary Vein: Cadaveric Study and Anatomical Evidence.

BACKGROUND: Additional second vessels may be required to handle multiple flaps used to add breast volume, boost blood flow for supercharging, or use salvage recipient vessels. In these situations, retrograde internal mammary vessel flow can be used although this causes doubts and concerns. PATIENTS AND METHODS: Forty sides of the chests of 20 fresh cadavers with intact thoracic cages and internal mammary veins (IMV) were used in the study. IMV valve numbers and locations were checked, and the bifurcation was confirmed. A retrograde fluorescent angiography and a saline infusion test were followed to confirm flow direction. RESULTS: Twenty-eight vessels were identified in 40 sides of the chest; of them, 45% had no valves. A mean 0.7 valves per chest side were identified; 23 (82.1%) of 28 valves were located above the second intercostal space (ICS). A mean 1.76 communicating veins were found between the IMV bifurcation. In all cadavers, a crossing vein connecting the left and right medial IMV was confirmed just below the xiphoid process. Fluorescent angiography and a saline infusion test proved that the retrograde flow was caudal through the bifurcated IMV to the communicating, intercostal, and crossing veins. CONCLUSION: The IMV valve was present in 55% of our subjects and located concentrically above the second ICS level. It is highly unlikely that the retrograde flow was disturbed because the retrograde anastomosis level was below the second ICS. Furthermore, the bifurcation, intercostal, and crossing veins across the xiphoid process enabled valve-less detour flow. Thus, retrograde IMV flow is considered safe.