Treatment Effectiveness and Recurrence of Extracranial Arteriovenous Malformations Following Surgical Operations: A 15-Year Retrospective Cohort Study.

BACKGROUND: At present, there is no golden standard for treatment of extracranial arteriovenous malformations (AVMs) and recurrence remains a major challenge with limited available evidence on the associated factors. This study aimed to evaluate the effectiveness of surgical treatment options, in terms of size reduction, symptoms, and early recurrence in patients treated surgically for AVMs. METHODS: A retrospective cohort study was conducted to evaluate patients with AVMs following surgical treatment in 2 centers from 2005 to 2020. Posttreatment lesion size and symptoms, as well as recurrence, were assessed. Multiple regression analysis was performed to identify factors associated with recurrence. RESULTS: Forty-four surgical treatment cases in 31 patients were assessed with a mean follow-up duration period of 67.9 ± 39.5 months. Treatment included total resection in 26 cases (59.1%) and partial resection 18 (40.9%), with free flap coverage used in 19 cases (43.2%). No acute exacerbation following treatment was observed in our cohort. Total resection significantly reduced posttreatment lesion size ( P < 0.001), symptoms ( P < 0.001), and recurrence (20.0%, P = 0.03). The recurrence rate was significantly higher after partial resection (73.7%, P = 0.03). Total resection was identified as an associated factor for significantly reduced AVM recurrence (odds ratio: 0.12; 95% confidence interval: 0.03, 0.52). However, the use of free flaps did not significantly reduce recurrence, post treatment size or improve AVM symptoms. CONCLUSIONS: Total resection is the optimal treatment for AVMs. Free flaps are useful in covering large defects but the regulative effect of free flap remains controversial.

Microsurgical Treatment for Arteriovenous Malformations in the Hand.

Vascular malformations in the extremities are a common site of occurrence; arteriovenous malformations (AVMs) are the least frequent of all vascular malformations, estimated at 5% to 20%. The first step in management is to perform a thorough clinical examination. Symptoms are assessed, and staging is performed using the Schobinger classification. Next, ultrasonography and contrast-enhanced computed tomography are used to confirm the diagnosis of AVM and to confirm the extent of the malformation. Surgery is the first-line treatment and reconstruction is performed. In cases where surgery is not feasible, embolization and sclerotherapy may be used to alleviate symptoms.

Anatomical external auricular muscle transposition with mini flap transfer for mild cryptotia: A case report.

Cryptotia is a congenital ear deformity characterized by the upper helix buried under the skin of the temporal region. Recurrence and inadequate correction of ear position are major complications following auricle reconstruction. Abnormalities of the auricular muscles are closely associated with cryptotia and considered to be the main cause. However, current corrective procedures focus on provision of additional skin and abnormal auricular muscle correction is considered supplementary. We report a surgical approach focused on the anatomical repositioning of the external auricular muscle insertions and skin cover with a mini flap. Two consecutive patients aged 6 and 14 years with mild cryptotia (minimal auricular cartilage deformity) were treated using this technique with a follow-up duration of 12-25 months. The abnormal insertion of the superior auricular muscle (SAM) to the superior helix was repositioned to its correct anatomical position below the eminence of the triangular fossa, effectively moving the ear posterosuperiorly. No complications occurred postoperatively, the increase in vertical length of the superior helix to the superior ear attachment was 7.8 and 7.9 mm at 6months. Both patients could wear facemasks comfortably without them sliding off and were satisfied with the esthetic results. Total follow-up duration was 3 years in Case 1 and 4.4 years in Case 2. Primary correction of the SAM to its anatomical position may be a useful method for reducing the size of the skin flaps required with minimal donor site morbidity in reconstruction of mild cryptotia.

Safety of SARS-CoV-2 Vaccination in Patients with Vascular Malformations: Patient-Reported Adverse Vaccine Reactions.

Objectives: Concerns among susceptible individuals, especially those with vascular malformations, have been raised by reports of thromboembolism following the administration of the SARS-CoV-2 vaccination against coronavirus disease 2019 (COVID-19). This study's goal was to assess any negative side effects that patients with vascular malformations who received the SARS-CoV-2 vaccine reported after receiving it. Materials and Methods: Through the three patient groups for vascular malformations in Japan in November 2021, a questionnaire was distributed to patients with vascular malformations who were 12 years of age or older. Multiple regression analysis was used to find relevant variables. Results: A total of 128 patients responded, representing a response rate of 58.8%. Ninety-six participants (75.0%) had received at least one dose of SARS-CoV-2 vaccine. In total, 84 (87.5%) and 84 (89.4%) subjects experienced at least 1 general adverse response following dose 1 and dose 2, respectively. Adverse reactions related to vascular malformations were reported by 15 participants (16.0%) after the 1st dose and 17 (17.7%) after the 2nd dose. Notably, no case of thromboembolism following vaccination was reported. Conclusion: The rate of vaccine-related adverse reactions in patients with vascular malformations is not different from that reported in the general population. There is no report of life-threatening responses in the research population.

Structural and functional analysis of the newt lymphatic system.

Regeneration competent vertebrates such as newts and salamanders possess a weakened adaptive immune system characterized by multiple connections between the lymphatic system and the blood vascular system called lymphatic hearts. The role of lymphatic vasculature and these lymphaticovenous connections in regeneration is unknown. We used in-vivo near-infrared lymphangiography, ultra-high frequency ultrasonography, micro-CT lymphangiography, and histological serial section 3-dimentional computer reconstruction to evaluate the lymphatic territories of Cynops pyrrhogaster. We used our model and supermicrosurgery to show that lymphatic hearts are not essential for lymphatic circulation and limb regeneration. Instead, newts possess a novel intraosseous network of lymphatics inside the bone expressing VEGFR-3, LYVE-1 and CD-31. However, we were unable to show Prox-1 expression by these vessels. We demonstrate that adult newt bone marrow functions as both a lymphatic drainage organ and fat reservoir. This study reveals the fundamental anatomical differences between the immune system of urodeles and mammals and provides a model for investigating lymphatics and regeneration.

Tsugishige Kondo, The Father of Japanese Surgery: Exploring the History of Hideyo Noguchi's Hand Reconstruction With a Forearm Flap Before the Establishment of Plastic Surgery in Japan.

ABSTRACT: Hideyo Noguchi is one of the most famous scientists in Japan's history, and his portrait has adorned the ¥1,000 banknotes since 2004. He had a childhood burn injury resulting in severe hand scarring and contracture that plagued his early life and education.The resulting hand deformity required 3 separate reconstructions with the third and most complex surgery performed by Professor Tsugishige Kondo just before Noguchi's final medical doctor license examination in 1897. In this surgery, Kondo released the contractures using the first radial forearm flap performed in Japan long before the establishment of plastic surgery in the country.Reviewing the history of Kondo, we find that he likely learned the art of reconstructive surgery along with many other surgical techniques during his stay in Europe from 1891 to 1896 where he was mentored by 4 prominent surgeons of the era: Christian Albert Theodor Billroth, Vincenz Czerny, James Israel, and Carl Nicoladoni. During this period, Czerny reported performing the world's first breast reconstruction using lipoma transfer, and Nicoladoni performed the world's first thumb reconstruction with a chest flap and with toe-to-thumb transfer. Kondo may have watched these world's first operations and may have also been taught these innovative techniques including the forearm flap directly by these pioneers. He returned to Japan and successfully applied these reconstructive surgery methods in his practice and teaching, as evidenced by the landmark surgery of Hideyo Noguchi's hand, and laid the foundations for the development of plastic surgery in Japan.

Lymphaticovenular anastomoses training model for multiple stages of lymphedema by using efferent lymphatic plexus of the mesenteric lymph node of rats.

INTRODUCTION: Lymphaticovenular anastomosis (LVA) has transformed lymphedema treatment and has become an important part of the surgical therapy. LVA requires supermicrosurgical skills and unique nontraumatic techniques as the lymphatic vessel diameter of varies with the progression of lymphedema from 0.3 to 0.8 mm. However, even though several supermicrosurgical vessel anastomosis training models have been reported, only few focus on LVA including both various sizes of lymphatic vessels and lymphatic dissection. We report the establishment of a novel in-vivo LVA training model using the rat efferent lymphatic plexus of the mesenteric lymph node. MATERIALS AND METHODS: Lymphatic vessels in the efferent lymphatic plexus of the mesenteric lymph node and mesenteric veins of 10 male Wistar rats, 572-850 g, were used for LVA in an intima-to-intima coaptation manner using 12-0 nylon suture with 4-6 stitches in an end-to-end fashion. Postoperative patency was evaluated with indigo carmine blue after completion of anastomosis. Diameters of lymphatic vessels in the plexus and recipient veins were measured. RESULTS: The diameters of lymphatic vessels in efferent lymphatic plexus of the mesenteric lymph nodes and mesenteric veins used as recipients were measured in all 10 male rats. The mean number of lymphatic vessels included in efferent lymphatic plexus of the mesenteric lymph nodes was 7.5 (range, 5-11) and the mean diameter of the lymphatic vessels was 0.34 mm (range, 0.1-1.2 mm). The mean diameter of lymphatic vessels used for LVA was 0.46 mm (range, 0.25-0.7 mm). The mean diameter of the recipient veins was 0.49 mm (range, 0.35-0.7 mm). The postoperative patency rate after LVA was 100% (10/10). CONCLUSION: We reported the establishment of LVA model involving the use of the efferent lymphatic plexus of the mesenteric lymph node and mesenteric veins in rats.

Intra-lymphocele microsurgical identification of causative afferent vessels for effective lymphaticovenular anastomosis in lymphocele treatment: A case report.

Lymphoceles are an important complication of pelvic and abdominal surgery with a reported incidence of 11%-88%. Conventional treatment includes compression, puncture aspiration, sclerotherapy, and ligation but recurrence is not uncommon and is difficult to treat. Recently, microsurgical lymphaticolymphatic anastomosis, lymphaticovenular anastomosis (LVA) and reconstruction of lymphatic circulation with flaps are increasingly being utilized for lymphocele treatment. Effective microsurgical treatment requires precise identification of the causative afferent vessels for the most efficient circulatory by-pass. However, direct identification of these vessels using traditional lymphoscintigraphy and near infrared lymphography is challenging and often not possible. We report the case of a 55-year-old woman who presented with bilateral inguinal lymphoceles and lymphedema following pelvic surgery for vulvovaginal cancer. Bilateral multiple LVAs of the lower extremities were performed and the lower limb circumferences reduced postoperatively, however both lymphoceles still persisted. The patient was successfully treated by approaching the lymphoceles from inside the lymphocele cavity. The causative afferent lymph vessels were directly identified microsurgically by gentle pressure on the inner wall and causative afferent lymph vessel lymphaticovenular anastomosis was performed. The lymphoceles resolved promptly after surgery without complications, and no recurrence was observed on 5 years follow-up. This case report presents an innovative microsurgical approach to lymphocele treatment, including examination and techniques to identify the causative afferent lymphatic vessels for effective anastomosis. We report this case to demonstrate the importance of lymphatic vessel selection in the microsurgical treatment of lymphocele.

Skin graft fixation with negative pressure wound therapy with instillation and dwelling (NPWTi-d) for contaminated complex wounds of the extremities.

Objective: Negative Pressure Wound Therapy (NPWT) is increasingly being used as a major method of skin graft dressing and fixation. Negative Pressure Wound Therapy with Instillation and Dwelling (NPWTi-d) further enhances wound care over regular NPWT. However, only a few reports have been made on its use for skin graft fixation due to concerns of graft maceration or detachment. We used NPWTi-d to fix skin grafts for 4 cases of severely contaminated complex posttraumatic wounds. Methods: The age ranged from 37 to 72 years, and included trauma of the lower leg, forearm dog bite and incomplete amputations of the upper arm and hand respectively. The mean instillation saline volume per wound size was 0.21 ml/cm2 and the dwelling time reduced to 3 min. The NPWTi-d skin graft fixation was removed after about a week. Results: All the grafts healed well and no complications such as infection or contracture were observed. Follow-up time was 1 -8 months. Conclusions: NPWTi-d may be a useful option for fixing skin grafts particularly in contaminated wounds with a high risk of infection.

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis.

BACKGROUND: Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa. METHODS: Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates. RESULTS: Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84). CONCLUSION: This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care. REVIEW REGISTRATION: Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Accelerated Cranioplasty with Perforator-preserved Split Flap Sandwiched Plate for Treatment of Infected Cranial Defects.

Large cranial vault defects are challenging to manage due to the need to balance infection control, skin coverage, and restoration of the protective mechanical rigidity of the skull while also ensuring good head and neck aesthetic results. Conventional-staged treatment requires a long time period that includes debridement and scalp skin defect coverage with flaps as a first step, followed by definitive plate reconstruction 3-9 months later after infection control and flap atrophy resolution. We report a case of successful early cranioplasty in a factory worker who developed a large full-thickness cranial skull defect following artificial dura infection. Reconstruction was performed in two stages using an anterolateral thigh (ALT) flap. In the first stage, the scalp defect was covered with an ALT flap to close the skin following debridement. In the second stage performed 6 weeks later, the ALT flap was split into adiposal and adipocutaneous flaps to sandwich a computer-aided design custom-made titanium plate with an opening for the perforator to complete the cranioplasty. The patient successfully returned to work without recurrence of infection with 1-year follow-up. We report this case to demonstrate the utility of adipocutaneous flap plate sandwiching techniques in providing well-vascularized cover for early definitive cranial reconstruction and accelerated patient recovery.

Treatment of cold intolerance following finger pulp amputations: a case comparison between immediate finger replantation and delayed pulp and digital arterial arch reconstruction with flow-through free hypothenar flap.

We report a unique case of cold intolerance following identical fingertip amputations of two fingers on the same hand. The index finger was replanted and the middle finger was reconstructed with a free flow-through hypothenar perforator flap to anatomically restore the digital arterial arch circulation and successfully treat cold intolerance.

Successful Treatment of Ulcerative-Type Pyoderma Gangrenosum with a Combination Therapy of Oral Prednisolone, Vacuum-Assisted Closure, and Skin Grafting.

Pyoderma gangrenosum (PG) is a relatively rare inflammatory skin disease that progressively causes necrotic ulceration mainly on the lower extremities and trunk. Systemic corticosteroid is considered a first-line treatment for PG as it facilitates wound healing; however, several cases where tumor necrosis factor-α inhibitors, adalimumab and infliximab, were administered showed good response. For intractable PG with a large ulcer or problematic epithelization, chemical or mechanical debridement of necrotic tissue in combination with skin grafting may be necessary to promote wound healing. Our report presents a case of intractable ulcerative PG requiring oral prednisolone and skin grafting. Although mechanical debridement was performed, granulation was poor; therefore, after the PG activity became quiescent, we utilized a vacuum-assisted closure (VAC) system to promote granulation and adaptation of the grafted skin. Although more cases are required for a definitive conclusion, the VAC system may be a choice for PG with large ulcers.

Dual imaging lymphangiography guided treatment of infantile chylothorax.

Chylothorax is a potentially fatal postoperative complication of neck, thoracic, and abdominal surgery in children. We report the case of a 3-month-old infant who developed persistent chylothorax with respiratory insufficiency successfully managed using a microsurgical technique and intraoperative embolotherapy. This was achieved using a combination of intermittent digital X rays and live near-infrared fluorescence imaging we have termed "dual imaging lymphangiography" to guide therapy in real time. The chylothorax resolved and the patient returned to normal diet without recurrence. This microsurgical approach with dual imaging lymphangiography provides a useful tool for intraoperative visualization and treatment of complicated chylothoraces.

Laparoscopic repair of segmental obturator nerve injury defect using an artificial nerve conduit: A case report.

Obturator nerve injury is an uncommon complication frequently associated with pelvic gynecologic or urologic cancer surgery. It can lead to disability or adversely affect quality of life. Large segmental defects are particularly difficult to manage as the limited mobility of the nerve prevents tension-free direct end-to-end anastomosis. A 36-year-old woman with cervical cancer underwent sentinel lymph node biopsy, laparoscopic radical hysterectomy, and bilateral adnexectomy. During the procedure, the sentinel lymph node (right obturator node) adherent to the obturator nerve was resected together with the nerve segment leaving a 3 cm defect. Immediate laparoscopic obturator nerve repair was performed using an artificial nerve conduit leading to successful recovery. We report this unique case due to rarity of large segmental obturator nerve defects and present laparoscopic nerve repair with artificial nerve conduits as a useful treatment alternative of these important injuries, without nerve donor site morbidity.

Posterior auricular artery free flap reconstruction of the retroauricular sulcus in microtia repair.

BACKGROUND: Autologous repair using costal cartilage grafts remains the most widely accepted method of microtia reconstruction. A major complication of current techniques is loss of ear shape caused by scarring, contracture and cartilage absorption. We present a new surgical technique utilizing the posterior auricular artery free flap in microsurgical reconstruction of the retroauricular sulcus in microtia. METHOD: Reconstruction is performed in two stages. In the first stage, a fabricated costal cartilage framework is inserted into a skin pocket as described by Nagata. In the second stage, the ear framework is elevated from the scalp and held by an additional cartilage wedge. Following indocyanine green angiography perforator mapping, a posterior auricular artery perforator flap is harvested from the contralateral (normal) ear and used to reconstruct the posterior auricular sulcus covering the cartilage framework and elevating wedge. RESULTS: The technique was applied to three patients aged 11-15 years with a follow-up time of 8 months to 3 years. The average flap artery diameter was 0.73 mm and the vein was 0.7 mm. Venous congestion occurred in one case and was resolved with a vein graft leading to complete flap recovery. Good ear shape, elevation, projection, skin color and texture were achieved in all the cases. CONCLUSION: Posterior auricular artery flap reconstruction of the retroauricular sulcus in microtia repair is a useful alternative to the current skin graft and tissue expander-based techniques. It provides the ideal skin color and texture match and may improve the overall results of microtia reconstruction by enhancing vascularity.

Successful treatment of large abdominal lymphatic malformations and chylous ascites with intra-abdominal lymphovenous anastomosis.

Large abdominal lymphatic malformations (LMs) are rare and may occasionally cause life-threatening illness, especially when they involve the central lymphatic system, lumbar trunks, cisterna chyli, thoracic duct, and their major tributaries, forming complex lymphatic anomalies. These LMs are often accompanied by chylous leak in various locations, and treatment remains challenging. We report a case of large abdominal LM with chylous ascites, protein-losing enteropathy, vaginal chylous leak, and lower limb lymphedema successfully treated with microsurgical intra-abdominal lymphovenous anastomosis and discuss the technical details of the procedure.