Super-Microsurgery for Vessels with Diameters Smaller Than 0.5 mm.

Introduction: Among super-microsurgical techniques, the anastomosis of vessels smaller than 0.5 mm is very difficult to perform due to the small diameter and thinness of the blood and lymphatic vessel walls. In this article, we report on the main points of super microsurgery, particularly on the anastomosis of veins and lymphatic vessels with diameters smaller than 0.5 mm. Methods and Results: Details of anastomosis of vessels smaller than 0.5 mm. (1) The outer wall of the first blood vessel near the abrupt end hook with the tip of the needle in the needle holder. The entire abrupt end of the first blood vessel was supported by forceps in the surgeon's left-hand. (2) The surgeon decided the entry point and angle of the needle while moving the tip. After the needle was fixed, a force was applied so that the needle could pass through to the vascular wall. (3) After the needle passed through, the tip was confirmed to be located in the lumen of the first blood vessel. (4) The tip of the needle was inserted into the lumen of the second blood vessel, and the bite was adjusted while touching the second blood vessel through the endometrium. (5) Once the tip was properly positioned, counter-traction was applied by holding the entire outer wall with a left-hand forceps. (6) The needle was held near the tip and pulled out along its curvature. The anastomosis time was 11.35 minutes on average (9 to 14 minutes). The patency rate for all 20 anastomosis procedures was also 100%. Conclusion: The important points of LVA for lymphatic vessels and veins smaller than 0.5 mm were reported. Once the surgeons are familiarized with this anastomosis procedure, they can typically perform one anastomosis in about 10 minutes.

Exoscope and Supermicrosurgery: Pros and Cons of 3D Innovation in Lymphatic Surgery.

Background: The surgical treatment of lymphedema has seen advancements in recent years, with supramicrosurgical lymphaticovenular anastomosis (sLVA) gaining global acceptance. The integration of 3D exoscopes into microsurgery offers potential ergonomic and educational benefits. However, systematic evaluation of their efficacy in sLVA remains limited. Methods: A retrospective cross-sectional study was conducted comparing the use of 3D exoscopes to conventional operating microscopes (OM) in sLVA surgeries. Patient data from January 2019 to January 2024 were reviewed, with demographic, clinical, and surgical outcome variables analyzed. Ergonomic assessments were performed using Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA), while surgeon satisfaction was evaluated through the Microsurgical Intraoperative Satisfaction and Comfort questionnaire (MISCq). Results: An analysis of 25 patients (OM group: n = 14; exoscope group: n = 11) revealed no significant differences in age, sex, etiology, or surgical site between the two groups. Surgical time, number of incisions, and number of anastomoses showed nonsignificant variations between the OM and exoscope groups. Ergonomic assessments indicated potential benefits with exoscope use, particularly for the assistant surgeon. Survey results demonstrated comparable levels of surgeon satisfaction with both instruments, with no significant differences in image quality, contrast, illumination, magnification, visual field, ergonomic maintenance, or stereoscopic orientation. Conclusions: The study suggests that 3D exoscopes are a valuable tool for sLVA supermicrosurgery, offering comparable outcomes to traditional microscopes with potential ergonomic advantages. Their integration into microsurgical practice may contribute to improved surgical comfort and team performance. Further research is warranted to confirm these findings and explore additional factors such as cost-effectiveness and long-term patient outcomes.

Primary LYmphedema Multidisciplinary Approach in Patients Affected by Primary Lower Extremity Lymphedema.

Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system, leading to its malfunction. Various surgical options, including physiologic and excisional procedures, have been proposed. The aim of this study was to present a comprehensive algorithm for the treatment of primary lower extremity lymphedema: the Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated following the P-LYMA protocol. Patients underwent pre- and postoperative complex decongestive therapy (CDT). A variety of physiologic and excisional procedures were performed, either independently or in combination. The primary outcome was to assess the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of cellulitis episodes, and complications were recorded. Results: The mean CRR was 73 ± 20% at twelve months postoperatively. The frequency of cellulitis episodes per year decreased from a mean of 1.9 ± 0.8 preoperatively to 0.4 ± 0.6 during follow-up. Two patients experienced minor complications. The mean hospitalization time was 5 days. Patients' quality of life, as measured by the LeQOLiS, significantly improved from 70.4 ± 12 preoperatively to 24 ± 14 at twelve months postoperatively. Conclusions: The P-LYMA algorithm maximizes surgical outcomes and improves the quality of life in patients with primary lymphedema. CDT is essential for optimizing results.

The Superficial Circumflex Iliac Artery Perforator Flap for Head and Neck Reconstruction.

Head and neck defects present a unique challenge in reconstructive surgery due to the complex anatomy of this area. Different defects often require a variety of reconstructive techniques. The superficial circumflex iliac artery perforator (SCIP) flap is particularly notable for its versatility in this context. It provides a thin, pliable skin island that can be integrated with bone, muscle, fascia, and other structures. Additionally, the morbidity associated with the donor site of the SCIP flap is generally low and well tolerated. This article offers a comprehensive overview of the evolution of this technique.

Effectiveness of 1α-25-dihydroxyvitamin D3 active substance on anastomosis safety in the rat femoral artery end-to-end anastomosis experimental model: Macroscopic and histological analyses.

Under inflammatory conditions, macrophage dominance affects the degree of inflammation. We assessed the effects of the active vitamin D (calcitriol) administration on inflammatory processes and macrophage dominance and aimed to determine the potential positive macroscopic and histological effects in supermicrosurgical arterial anastomosis model of rats. Forty rats were divided into five groups: control surgery (Group 1), surgery with preoperative (Group 2), post-operative (Group 3), perioperative (Group 4) systemic calcitriol and surgery with local calcitriol (Group 5). Eighty femoral artery anastomoses were planned in both legs of rats. Systemic calcitriol was administered intraperitoneally daily to the animals in the relevant groups. Preoperative vessel diameter measurements were taken before anastomosis. Three weeks post-surgery, post-operative vessel diameter measurements were taken, anastomosis patency was assessed and vascular segments were collected for histological examination, which included assessment of M1 and M2 macrophage depolarisation, leucocyte infiltration, intima-media ratio and luminal gap scoring. Systemic calcitriol administration (pre-, post- or perioperative) significantly improved the vessel diameter (p < 0.001); there was no significant difference among Groups 2-4. Histological findings revealed that Groups 3 and 4 had lower intima-media ratios (p < 0.05 and p < 0.01), higher M2-M1 macrophage ratios (p < 0.01 and p < 0.001) and lower leucocyte infiltration (p < 0.05, p < 0.01 and p < 0.001). Local calcitriol administration had no vasodilatory effects or resulted in positive histological outcomes. Although the administration of calcitriol pre- and post-operatively increased the vessel diameter, the latter appeared to have a more favourable impact on the histological analyses.

Various handcrafted artificial vessels: Evaluation of practicality and feasibility for supermicrosurgery training.

BACKGROUND: Supermicrosurgery demands more refined skills compared to traditional microsurgery, necessitating comprehensive training prior to clinical implementation. Despite the existence of various training models, they often fall short in terms of cost, ethical considerations, and infection risk. Our objective was to develop and evaluate novel training models for supermicrosurgery that are cost-effective, ethical, and risk-free. METHODS: We fabricated tubes using polyvinyl alcohol (PVA) liquid glue, polyvinyl acetate resin (PAR) wood glue, and hydrocolloid dressing (HCD), aiming to identify suitable, low-cost candidates for a supermicrosurgery training model. These tubes were anastomosed under a microscope using 10-0 or 11-0 nylon sutures. We assessed the time and cost involved in tube fabrication, their diameters, and the overall feasibility of the models. RESULTS: The average time and cost to fabricate a 15-mm-long luminal tube were 33.5 min and 0.02 USD for the PVA group, 23 min and 0.02 USD for the PAR group, and 63 s and 0.40 USD for the HCD group, respectively. The average diameter of the tubes was 0.49, 0.58, and 1.55 mm in the PVA, PAR, and HCD groups, respectively. The PVA and PAR tubes, with their transparent and thin walls, facilitated easier evaluation of anastomosis patency compared to the HCD tubes. CONCLUSION: We successfully used non-living materials to develop new supermicrosurgery training models, characterized by their low cost, absence of ethical concerns, and elimination of infection risk. The PAR and PVA tubes, in particular, are suitable for resident training in supermicrosurgery.

Nylon Suture Loop for Tagging Lymphatic Channels during Lymphaticovenular Anastomosis.

Background Lymphaticovenular anastomosis (LVA) requires special supermicrosurgery techniques designed for vessels less than 0.8 mm in size. While preparing the field for LVA, it is often difficult to handle the lymphatic vessel directly without injuring it or fracturing it entirely. Method We propose a novel technique, which is used in LVA for tagging of lymphatic vessels, with the use of a nylon 6-0 suture and micro-ligaclip. Results We have successfully performed 78 LVAs in 26 cases with this method. The average lymphatic vessel size was 0.3 mm (0.15-0.8 mm). Conclusion This novel technique to implement the use of a nylon suture with a micro-ligaclip to use as a vessel loop for lymphatics has not been previously described in the literature. It is a useful technique that we find beneficial to lymphatic identification through tagging of the lymphatic channels, contributing to greater success in each anastomosis.

Lymphaticovenous anastomosis in rabbits: A novel live experimental animal model for supermicrosurgical training.

BACKGROUND: Lymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination. METHODS: An experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples. RESULTS: The patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed. CONCLUSION: This study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature.

Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL).

PURPOSE: Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL). METHODS: A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications. RESULTS: A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group. CONCLUSIONS: Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction.

Robotic-assisted microsurgery has gained significant attention in recent years following the introduction of two dedicated microsurgical robotic systems specifically designed for this purpose. These feature higher degrees of movement and motion scaling which are useful tools, especially when performing surgery in areas of the body which are difficult to access. Robotic-assisted microsurgery has been implemented in lymphatic surgery as well as soft tissue reconstructive surgery at our institution over the past 2.5 years. Our study gives an insight into the details and outcomes of the first 100 consecutive (super-) microsurgical anastomoses in peripheral and central lymphatic reconstruction performed with the Symani® Surgical System between 2021 and 2024. In total, 67 patients were treated, receiving robotic-assisted lymphatic reconstruction with lymphatic tissue transfer (LTT) and/or lymphovenous anastomoses (LVA)/lympholymphatic anastomoses (LLA). No anastomosis-associated complications were recorded postoperatively. The majority of patients reported a postoperative improvement of their lymphedema or central lymphatic disorder. In conclusion, we show the successful implementation of the Symani® Surgical System into our clinical practice of lymphatic reconstruction. Although the necessary intraoperative setup and the use of intrinsic motion scaling lead to a slight increase in operating time, the presented study demonstrates the advantages of robotic assistance which becomes particularly evident in lymphatic surgery due to the involved deep surgical sites and the need for supermicrosurgical techniques.

Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention.

OBJECTIVE: We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS: This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS: A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS: Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.

Replantation of digit-tip amputation caused by crush injuries with supermicrosurgery technique.

PURPOSE: Digit-tip amputation caused by crush injury is a common emergency scenario, and the management is full of challenges. The objective of this study was to demonstrate the application of the supermicrosurgery technique in replantation procedures for complex digit-tip amputations resulting from crush injuries, while also assessing functional and aesthetic outcomes. METHODS: We conducted a retrospective analysis of the data from 12 patients who underwent replantation of 15 digits in our department between July 2022 and June 2023. The outcomes of replantation, functional recovery (including return to work, cold tolerance, bone union, DASH score, VAS score, and two-point discrimination test), aesthetic results (including digit appearance, nail deformity, and pulp atrophy), and patient satisfaction were assessed. RESULTS: The amputation of 7 digits occurred within Tamai zone I level, 8 digits within Tamai zone II level, while 4 digits occurred within Ishikawa zone I level, 3 digits within Ishikawa zone II level, 7 digits within Ishikawa zone III level, and 1 digit within Ishikawa zone IV level. The replanted digits all survived (100%) without any indications of arterial insufficiency or venous congestion. The follow-up procedures were conducted on all 12 patients, with an average duration of 9.6 months (range, 6 to 18 months). The fracture successfully underwent healing at 9.2 weeks (range, 8 to 13 weeks). The mean VAS score was 1.75 points (range 0 to 4 points), the mean two-point discrimination test result was 5.72 mm (range 4.0 to 7.0 mm), and the mean DASH score was 9.78 points (range 3.33 to 22.5 points). All patients demonstrated cold tolerance and successfully resumed their pre-injury occupational activities. The nail deformity was observed in one digit following replantation within Tamai zone I, and in three digits following replantation within Tamai zone II; moreover, eight digits exhibited varying degrees of pulp atrophy. All patients expressed satisfaction with both functional and aesthetic outcomes. CONCLUSION: The successful replantation of digit-tip amputation caused by crush injury can be achieved through the application of supermicrosurgery technique, resulting in improved functional and aesthetic outcomes. Digit-tip replantation is a favorable and meaningful procedure with high patient satisfaction.

Use of supermicrosurgery in craniofacial and head and neck soft tissue reconstruction: a systematic review of the literature and meta-analysis.

Supermicrosurgery is an evolving approach in the reconstruction of head and neck (HN) and craniofacial (CF) defects. This systematic review aims to evaluate the use of supermicrosurgery for arterial or combined arterial and venous anastomoses in the reconstruction of HN and CF soft tissue defects, and the associated success, total complication, and reoperation rates. A literature search was conducted on PubMed, Dynamed, DARE, EMBASE, Cochrane, and British Medical Journal (BMJ) electronic databases (PROSPERO ID: CRD42023476825). Nine studies fulfilled the inclusion criteria with 35 patients who underwent soft tissue reconstructive procedures using supermicrosurgery. Twenty-one flaps were performed on 20 patients (57.1%) with the remaining 15 patients (42.9%) undergoing supermicrosurgical replantation. The most common pathology requiring reconstruction was HN trauma (n = 16, 45.7%) followed by malignancy (n = 15, 42.9%). The pooled success rate for supermicrosurgery was 98% (95% CI 90 to 100, p = 1.00; I2 = 0%). The cumulative complication rate across all the studies was 46% (95% CI 13 to 80, p < 0.01; I2 = 0%), and the pooled rate of reoperation was 1% (95% CI 0 to 8, p = 0.23; I2 = 24%). The use of supermicrosurgery for HN and CF soft tissue reconstruction has an overall success rate of 98%, which is commensurate with traditional microsurgery for HN reconstruction. Complication and reoperation rates are comparable to previous literature. This study confirms the feasibility of supermicrosurgery as a safe and reliable reconstructive option for HN and CF defects.

Intravascular flipping technique for end-to-side microvascular anastomosis.

Recent advances in minimally invasive perforator flaps, such as the superficial circumflex iliac artery (SCIP) flap, have increased the demand for anastomosing vessels with diameters less than 0.8 mm. However, discrepancies in size can occur, underscoring the significance of end-to-side anastomosis. Nevertheless, the conventional interrupted end-to-side suturing technique with vessel turnover presents challenges in situations with a limited operative field, short vascular pedicle, and tiny vessels. Therefore, we developed an intravascular flipping technique for end-to-side microvascular anastomosis with an inside technique or rotation-outside technique. The study involved 20 rats and with 15 arteries in 10 rats undergoing the flipping technique with inside or outside rotation. Both the inside and rotation-outside techniques exhibited a 100% immediate patency rate in the rats; however, after 1 week, this decreased to 80% and 86%, respectively. The SCIP flap and replantation procedures were successfully performed. The flipping technique offers several advantages, including ease of vessel manipulation using nylon threads and vascular clips, improved vessel visualisation, and spontaneous widening of the vessel lumen.

Overlapping lockup lymphaticovenous anastomosis: A useful addition to supermicrosurgery.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is a minimally invasive surgical procedure used to treat lymphedema. This surgical procedure connects the superficial lymphatic vessels to nearby veins to establish lymphatic-venous pathways. One of the most common challenges encountered by lymphatic surgeons when performing LVA is a mismatch in the sizes of the veins and lymphatic vessels, with the effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of an overlapping lockup anastomosis (OLA) LVA technique to address these problems. METHODS: In this study, we present a novel OLA technique for LVA that addresses the challenges with conventional techniques. The OLA technique was used in 10 lymphedema patients between September 2022 and March 2023 to compare OLA and end-to-end anastomosis. The time required for anastomosis, method of anastomosis, patency rates, and lymphedema volume were evaluated in this study. RESULTS: Of 123 LVAs, 44 were performed using the OLA technique in 10 patients, with indocyanine green lymphangiography revealing unobstructed drainage. A single case of slight fluid leakage occurred, which was resolved by reinforcing the sutures. The average anastomosis time for OLA and the end-to-end technique was 5.55 minutes and 12.1 minutes, respectively. The wounds of the patients healed without infection, and the subjective limb circumference decreased. CONCLUSIONS: The OLA technique could serve as a valuable addition to the current LVA technique, especially for cases with a mismatch in the sizes of the lymphatic vessels and veins. This technique has the potential to promote the broader application of LVA in the treatment and prevention of lymphedema.

[Comparative analysis of the groin and SCIP flap in reconstructive microsurgery of soft tissues of the maxillofacial area and oral cavity]. / Sravnitel'nyi analiz pakhovogo i SCIP-loskuta v rekonstruktivnoi mikrokhirurgii myagkikh tkanei chelyustno-litsevoi oblasti i polosti rta.

Most of the articles on the groin flap were published in the period from 1975 to 2010, from 2015 to 2022, the SCIP flap surpassed the groin flap in the number of publications. According to the results of a literature search in PubMed and RINC, 30 articles were found and selected, including 288 flaps from the iliac region. The length of the vascular pedicle, the diameter of the vessels, the complications, the prevalence of the flap in the reconstruction of the head and neck, the thickness and the size of the flap were evaluated. Both of these flaps have the same nutrition, but different levels of dissection. In comparison with the groin flap, the SCIP flap has a longer vascular pedicle, which can be enlarged due to new techniques, which also allows it to be used as an ultra-thin flap, and it reduces the need for secondary procedures for defatting and reduces the risks of the complications in the donor area. The thickness of the SCIP flap is less than the groin one, which, according to the author, increases the aesthetic level of operations in the facial area in the case of the texture and color of the flap. Vascular anatomy of the SCIP flap is variable, therefore, the use of preoperative planning is necessary. Despite this, complications in the donor or recipient area during reconstruction with a SCIP flap are minimal. It has been proved that the SCIP flap is versatile and safe in all aspects of reconstruction. It can be concluded that the SCIP flap should be considered as a «workhorse¼ in reconstructive microsurgery of soft tissues of the throat and oral cavity.

Dual intravascular stent flipping technique for microvascular anastomosis.

The anastomosis of vessels <0.5 mm in diameter is challenging. We developed a supermicrosurgical anastomosis technique, the dual intravascular stent flipping technique with a double or single clip (dual flipping technique, double-clip technique, and single-clip technique). In the dual flipping technique, we used a 7-0 nylon intravascular stent and clipped the vessel along with the nylon. The double-clip technique was performed in 10 rats with 20 saphenous and 15 superficial inferior epigastric arteries. Immediate and 1-week patency rates were assessed. Subsequently, we examined ten epigastric arteries in five rats with the single-clip technique. The clinical application was performed in six cases involving finger/fingertip amputations, two cases involving radial artery superficial palmar branch flap, and one case involving superficial circumflex iliac artery perforator flap. Using the double-clip technique, the immediate patency rate was 90% and 93% in the saphenous and superficial epigastric arteries, respectively, whereas the 1-week patency rate was 81%. With the single-clip technique, the immediate patency rate was 100%. The replantation and flaps were successful. The advantages of the dual flipping technique included easy insertion, rare slipping-out possibility, and spontaneous vessel dilation by the flipped nylon. Additionally, the posterior vessel wall could be sutured more easily than could the anterior wall. By using the elasticity of the thread to invert the blood vessel, the posterior wall can be sutured without the double clip. When forceps tip insertion into the lumen is difficult, the dual flipping technique enables a relatively easy anastomosis if the 7-0 nylon is inserted into the vessel lumen.

Supermicrosurgery: past, present and future.

Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.

Clinical application of magnetic resonance lymphangiography in the vascularized omental lymph nodes transfer with or without lymphaticovenous anastomosis for cancer-related lower extremity lymphedema.

Background: The recent increase in the number of patients with lower extremities lymphedema and the development of microsurgery techniques have led to a rise in lymphedema treatment. Vascularized omental lymph node transfer (VOLT), an emerging treatment modality for extremity lymphedema, has shown its unique advantages in reconstructing lymphatic circulation and absorbing exudated lymphatic fluid. Patients who underwent radical tumor resection with/without radiation therapy treatment often present with impairment or degeneration of the inguinal lymph nodes. For such cases, VOLT could provide adequate lymph nodes and tissue to absorb edema fluid in these areas. Therefore, we analyzed the operative outcomes of VOLT under the guidance of magnetic resonance lymphangiography (MRL) in this study, as this individualized and precise surgical procedure could benefit patients and improve their quality of life. Methods: From November 2021 to September 2022, a total of 14 patients' 19 legs with extremity lymphedema underwent a VOLT with or without lymphaticovenous anastomosis (LVA). Outcomes, including circumference reduction rates, preoperative and postoperative MRL results, and other complications, were analyzed. Results: The mean follow-up period was 8.86±1.41 months (range, 7-11 months). The mean circumference reduction rates {circumference reduction rate (%) = [1 - (postoperative affected limb - healthy limb)/(preoperative affected limb - healthy limb)] × 100%} of different planes (i.e., ankle, 10 cm above the knee, 10 cm below the knee, 10 cm above the ankle, and 20 cm above the knee) were 15.64%±40.08%, 11.79%±30.69%, 20.25%±24.94%, 7.73%±30.05%, -1.517%±16.75%. Notably, one patient had multi-drug-resistant gram-negative infections, which resulted in the loss of three flaps. The postoperative MRL showed improved lymphatic drainage and lower extremity volume in the remaining 13 cases. Conclusions: The precision evaluation of inguinal lymph nodes and lower extremities lymphatic system through MRL using VOLT can provide surgeons with a comprehensive understanding and reliable evidence for the treatment of cancer-related lower extremity lymphedema.

Prophylactic Lymphovenous Bypass at the Time of Axillary Lymph Node Dissection Decreases Rates of Lymphedema.

Background: Breast cancer-related lymphedema impacts 30% to 47% of women who undergo axillary lymph node dissection (ALND). Studies evaluating the effectiveness of prophylactic lymphovenous bypass (LVB) at the time of ALND have had small patient populations and/or short follow-up. The aim of this study is to quantitatively and qualitatively evaluate prophylactic LVB in patients with breast cancer. Methods: A retrospective review of patients who underwent ALND from 2018 to 2022 was performed. Patients were divided into cohorts based on whether they underwent prophylactic LVB at the time of ALND. Primary outcomes included 30-day complications and lymphedema. Lymphedema was quantitatively evaluated by bioimpedance analysis, with L-dex scores >7.1 indicating lymphedema. Results: One-hundred five patients were identified. Sixty-four patients (61.0%) underwent ALND and 41 patients (39.0%) underwent ALND+LVB. Postoperative complications were similar between the cohorts. At a median follow-up of 13.3 months, lymphedema occurred significantly higher in the ALND only group compared with ALND+LVB group (50.0% vs 12.2%; P < 0.001). ALND without LVB was an independent risk factor for lymphedema development (odds ratio, 4.82; P = 0.003). Conclusions: Prophylactic LVB decreases lymphedema and is not associated with increased postoperative complications. A multidisciplinary team approach is imperative to decrease lymphedema development in this patient population.