Modified Preparatory Intravascular Stenting Technique in Super-microsurgical Lymphaticovenular Anastomosis for the Treatment of Lymphedema.

Clinical studies have reported that lymphaticovenular anastomosis (LVA) is more effective for early-stage lymphedema. However, the diameter of lymphatic vessels in early-stage lymphedema is thin (only about 0.3 mm). In this article, we report a modified preparatory intravascular stenting technique (PIST) for LVA with smaller lymphatic vessels and present the results of its application for the treatment of secondary lymphedema. In this technique, a 9-0 nylon thread is inserted into the target lymphatic vessel. Then, the thread is pulled until its tip has entered the lymphatic vessel. After that, the thread is allowed to proceed into the lumen by pushing it. Finally, with the nylon in place, the lymphatic vessel is transected and the lumen is secured. In this report, we investigated the surgical time for LVA between 10 patients who underwent LVA with modified PIST (group A) and another group of 10 patients who underwent LVA without the technique (group B). Lymphatic lumen was secured at all sites where indocyanine green lymphangiography confirmed lymphatic flow. The average outer diameter of lymphatic vessels in group A and B were 0.36 mm and 0.53 mm, respectively. The average surgical time for LVA in group A was 136 minutes, which was significantly shorter than the 187 minutes in group B. Our results indicated that modified PIST can help secure the lymphatic lumen even when the lymphatic vessels are thin. As a result, this technique can significantly reduce the surgical time for this procedure.

Abdominal Wall Incisional Hernia Repair with the Anterior Component Separation Technique and Reinforcement with an Anterior Rectus Abdominis Sheath Flap.

Mesh repair is currently the mainstay of treatment for abdominal wall incisional hernias and is considered the standard of care. However, if radiotherapy is used, the possibility of complications such as exposure or infection of the prosthesis after the surgery as a complication of the radiotherapy is a concern. The patient was a 51-year-old woman who underwent laparotomy by a mid-abdominal incision for ovarian tumors. Approximately 2 years later, the patient presented with a hypertrophic scar of the wound and mild pain in the scar. The hypertrophic scar was improved gradually by corticosteroid injection. However, she had a bulge on the left side of the umbilicus just below the hypertrophic scar. Computed tomography showed a 65 × 69 mm2 hernial orifice on the left side of the umbilical abdominal wall, and an abdominal wall incisional hernia was diagnosed. The patient underwent closure by the ACS technique and reinforcement by unilateral inversion of the anterior rectus abdominis sheath for the abdominal wall incisional hernia. No recurrence of the hypertrophic scar or abdominal wall incisional hernia was observed during the follow-up period. In the present case, the hernial orifice was closed by a modified ACS technique that was combined with the anterior rectus abdominis sheath turnover flap. This technique is likely a less invasive and relatively simple method resulting in a tighter repair of the abdominal hernia than the ACS method alone, without prostheses.

Axillary accessory breast cancer reconstructed by a thoracodorsal artery perforator flap: A case report.

INTRODUCTION: Primary accessory breast cancer is rare and most commonly occurs in the axilla. Due to its low incidence, few studies have discussed axillary reconstruction after accessory breast cancer resection. In the present report, we describe a patient who underwent axillary reconstruction with a thoracodorsal artery perforator (TAP) flap after resection, and reconstruction methods after resection of axillary accessory breast cancer are discussed based on current and previous reports. PATIENT CONCERNS: A 60-year-old woman presented with a 7-year history of a gradually growing lump in the left axilla. DIAGNOSIS: The patient was diagnosed with latent breast cancer, axillary lymph node metastasis, or carcinoma of the accessory axillary breast with axillary lymph node metastasis. INTERVENTIONS: After preoperative chemotherapy, tumor resection and axillary lymph node dissection were performed, followed by immediate axillary reconstruction using a TAP flap. The patient received postoperative adjuvant endocrine and radiation therapy (50 Gy). OUTCOMES: No recurrence or metastasis was observed for 5 years postoperatively. The reconstructed axilla was not bulky, and scar contracture was not observed, with a full range of motion of the shoulder joint. CONCLUSION: We described a patient who underwent immediate TAP flap reconstruction after resection of accessory breast cancer and axillary lymph node dissection, followed by postoperative radiation, which could cause scar contracture. The patient was followed up for more than 5 years after the operation and radiation therapy, and the appearance of the axilla and range of motion of the shoulder were good despite postoperative radiation.

An original method of analysis of the breast contour curve with 3-dimensional imaging: Case series.

INTRODUCTION: Postoperative assessment of breast reconstruction results has become increasingly important. In this paper, a unique analysis method with 3-dimensional surface images of patients who were treated with immediate breast reconstruction is presented. PATIENT CONCERNS: Five Japanese women were suspected of having breast cancer and visited our hospital for treatment. DIAGNOSIS: Breast cancer was diagnosed by biopsy, mammography, ultrasonography, computed tomography, and magnetic resonance imaging. INTERVENTIONS: Five patients underwent nipple/skin-sparing mastectomy, concomitant sentinel lymph node biopsy, and immediate breast reconstruction in our hospital. Three cases were reconstructed by extended latissimus dorsi flaps, one was reconstructed by a pedicled transverse rectus abdominis myocutaneous flap, and one was reconstructed by a deep inferior epigastric artery perforator flap. Three-dimensional photographs were taken 1 year postoperatively. The similarity of the breast contours between the reconstructed breast and the nonaffected opposite breast obtained from 3-dimensional images was analyzed. The calculated value is called the breast contour score. OUTCOMES: No recurrence was observed during the follow-up period in any cases. All cases could be analyzed by breast contour score to evaluate the breast shapes. CONCLUSION: The scores become a relative value that ranges from 0 (completely different) to 100 (completely the same). By expressing the score as a relative value, the breast contour score could help us understand the degree of breast symmetry more intuitively.

Lymphoscintigraphy for prediction of effect of lymphaticovenular anastomosis for treatment of secondary lower limb lymphedema.

OBJECTIVE: The outcomes of lymphaticovenular anastomosis (LVA), especially for the lower extremities, have varied. To determine the optimal patient selection for LVA, we evaluated the smooth muscle function of lymph vessels using preoperative lymphoscintigraphy images and compared the findings with the LVA outcomes. METHODS: We performed a retrospective study of 81 patients with secondary lower extremity lymphedema who had undergone LVA between 2016 and 2018. To reduce the variability in the surgeon-specific variables that can affect the outcomes of LVA, all the cases from 2016 onward were performed by only two surgeons using standardized protocols for preoperative care, surgical technique, number of anastomoses, postoperative ambulation, and compression. The outcomes were evaluated by comparing the circumferences of the pre- and postoperative limbs. The preoperative lymphoscintigraphy findings were categorized into three types according to the range of the cephalad extent of the tracer as follows: type 1, tracer extending to the thigh or groin region; type 2, tracer extending to the lower leg or knee; and type 3, tracer localized at the ankle. The quantitative outcomes were evaluated by measuring the circumferences of the ankle, mid-calf, knee, and thigh. RESULTS: The average percentage in the reduction in the ankle, mid-calf, knee, and thigh circumference was 7.9%, 4.7%, 2.9%, and 3.0%, respectively. The average percentage in the reduction in the circumference for types 1 and 3 at the ankle, mid-calf, knee, and thigh was 11.6% and 8.6%, 7.6% and 1.6%, 5.2% and -0.5%, and 5.4% and -1.2%, respectively, with significant differences between types 1 and 3 in the thigh. The percentage of types 1, 2 and 3 was 60% to 76.4%, 11.7% to 20%, and 0% to 5.5% of the treated limbs that were similar in size to the contralateral healthy limb at the four sites of measurement, respectively. CONCLUSIONS: The use of LVA can effectively reduce the circumference of the lower limb. Our results suggest that the lymphoscintigraphy findings could help to predict the effect of LVA and could facilitate optimal patient selection.

Massive non-incisional abdominal wall hernia caused by abdominal wall weakness resulting from childhood radiation therapy: a case report.

Huge abdominal wall hernias after radiation therapy in the absence of any previous surgical incisions or trauma are rare and, to the best of our knowledge, have not previously been reported. we report a patient with a massive hernia caused by abdominal wall weakness resulting from childhood radiation therapy.

Application of augmented reality (AR) technology to locate the cutaneous perforator of anterolateral thigh perforator flap: A case report.

Multi-detector row computed tomography (MDCT) makes it possible to visualize the peripheral perforators of the anterolateral thigh (ALT) flap. However, to transfer the preoperative MDCT angiography data to the operative field requires effective techniques. In this report, we describe an application of augmented reality (AR) technology to harvest the anterolateral thigh flap. A 36-year-old female presented with a T2N2 squamous cell carcinoma of the lateral tongue. The patient underwent hemiglossectomy and microsurgical reconstruction using the left ALT flap. Three dimensional (3D) images the vascular image, vascular with muscles and vascular with outline of the thigh ware prepared. Then these images were exposed to an AR device. The location of the perforator was determined using the 3D vascular image on AR. The intraoperative location of the cutaneous perforator corresponded with the predicted location which was confirmed using the AR technique. A 6 × 15 cm left ALT flap was transferred to the defect. Microsurgical anastomosis was performed on the left superior thyroid artery and the internal jugular vein. There were no complications during the postoperative course. At the 6-month follow-up, the patient showed no evidence of flap and donor site complications. Our experience suggests that AR technology may effectively support the transfer of MDCT angiography images onto surgical sites.

EEC-LM-ADULT syndrome caused by R319H mutation in TP63 with ectrodactyly, syndactyly, and teeth anomaly: A case report.

RATIONALE: Ectrodactyly ectodermal dysplasia-cleft lip/palate (EEC) syndrome, limb-mammary syndrome (LMS), and acro-dermato-ungual-lacrimal-tooth (ADULT) syndrome are caused by a TP63 gene disorder and have similar features. In the present article, a R319H mutation in TP63 is reported, and the correlation between genotype and phenotype is discussed based on the current case and previous literature. PATIENT CONCERNS: A 13-year-old Japanese boy had ectrodactyly in the right hand and left foot and syndactyly in the left and right foot, and tooth shape abnormalities. DIAGNOSES: Peripheral blood samples were obtained, and mutation analysis was performed. A heterozygous G>A transition at cDNA position 956 of the TP63 gene was found. The patient was diagnosed with ELA (EEC/LM/ADULT) syndrome based on his clinical features and mutation analysis results. INTERVENTIONS: The patient underwent surgery to correct the left foot malformation at 1 year of age and the right foot syndactyly at 11 years of age. OUTCOMES: No complications were observed after the first and second operations. He can walk comfortably after them, and no additional interventions will be planned in him. We continued to follow up with him up to the present. LESSONS: The concept of ELA syndrome, which is the original concept of combining 3 syndromes (EEC syndrome/LMS/ADULT syndrome) into a unique clinical entity, can help clinicians to better understand TP63-related syndromes and improve the differential diagnosis of these syndromes.

Lymph Vessel Mapping Using Indocyanine Green Lymphography in the Nonaffected Side of Lower Leg.

BACKGROUND: The lymph vessels from the dorsum and the medial ankle ascending to the medial side of the thigh toward the inguinal lymph nodes can be observed by the linear flow using indocyanine green near-infrared lymphography (ICGL). Although anatomical studies have shown the widespread existence of lymphatic vessels throughout the body, ICGL shows little linear flow. We herein report our findings of the course of lymph vessels in healthy lower limbs. METHODS: The unaffected lower limbs of 14 patients who underwent lymphaticovenular anastomosis were evaluated for this study. The results of linear flow without massage obtained using ICGL were recorded using a 3-dimensional camera. The positions of lymph vessels were measured from the baseline, which was drawn from the midline of the anterior thigh to the second toe through the middle point of the patella. The locations of the lymph vessels were analyzed using 3-dimensional images at the following 4 points: 10 cm above the knee, at the lower pole of the patella, at the middle aspect of the lower leg, and at the dorsum of the foot. RESULTS: The average distance from the baseline to the linear flow at each point was 11.39, 9.82, 4.37, and 0.97 cm, respectively. The linear flow was observed inside of the baseline at a distance equivalent to 27.2%, 30.1%, 14.8%, and 4.4% of the leg circumference. CONCLUSIONS: Lymph vessels were observed extensively in the middle lower leg. In contrast, linear flow was limited to a small area at the other measurement points. At 10 cm above the knee, 62.5% of the observed lymph vessels ran 11-12 cm inward from the baseline. Although these results can be useful when choosing incision sites for effective lymphaticovenular anastomosis, this is a pilot study of 14 patients, and studies on a large number of healthy legs need to be done in future.

Augmented Reality Technology for the Positioning of the Auricle in the Treatment of Microtia.

BACKGROUND: The positioning of the auricle is a key factor in successful ear reconstruction. However, the position of the ear is usually determined by transferring the auricle image of the nonaffected side to the affected side using a transparent film. Augmented reality (AR) is becoming useful in the surgical field allowing computer-generated images to be superimposed on patients. In this report, we would like to introduce an application of AR technology in ear reconstruction. METHODS: AR technology was used to determine the position of the reconstructed ear of a 10-year-old male with right microtia. Preoperative 3-dimensional photographs of the nonaffected side were taken using VECTRAH1. Then, the image was horizontally inverted and superimposed on the three-dimensional image of the affected side with reference to the anatomical landmarks of the patient's face. These images were projected onto the patient in the operation room using Microsoft's HoloLens. The design and positioning of the auricle was done with reference to the AR image. To confirm the accuracy of the AR technique, we compared it to the original transparent film technique. After the insertion of the cartilage framework into the skin pocket, the position and shape of the reconstructed ear was confirmed using the AR technology. RESULTS: The positioning of the reconstructed ear was successfully performed. The deviation between the 2 designated positions using the AR and the transparent film was within 2 mm. CONCLUSION: The AR technology is a promising option in the surgical treatment of microtia.

Tolvaptan can limit postoperative paroxysmal atrial fibrillation occurrence after open-heart surgery.

PURPOSE: Tolvaptan administration in the early postoperative period after cardiac surgery rapidly treats fluid retention without affecting the renal function. Tolvaptan also has the benefit of not stimulating the renin-angiotensin and sympathetic nervous systems, which are risk factors for postoperative paroxysmal atrial fibrillation. In this study, we examined the hypothesis that tolvaptan administration reduces postoperative paroxysmal atrial fibrillation and worsening of the renal function incidence in patients who have undergone open-heart surgery. METHODS: From our previous randomized study, we selected 166 open-heart surgery patients, divided them into 2 groups [tolvaptan group, 83 patients; control (non-tolvaptan) group, 83 patients], and compared the incidence of postoperative paroxysmal atrial fibrillation and worsening of the renal function in the postoperative period between the groups. RESULTS: The incidence of worsening of the renal function was significantly lower in the tolvaptan group than in the control group (4.8% vs. 15.7%; P = 0.04). The incidence of postoperative paroxysmal atrial fibrillation within 14 days was also significantly lower in the tolvaptan group than in the control group (26.5% vs. 42.2%; P = 0.011). CONCLUSION: Tolvaptan administration in the early postoperative period after open-heart surgery may reduce the incidence of postoperative paroxysmal atrial fibrillation and worsening of the renal function.

Debranching thoracic endovascular aortic repair for distal aortic arch aneurysm in elderly patients aged over 75 years old.

BACKGROUND: We examined the outcome of debranching thoracic endovascular aortic repair (d-TEVAR) without sternotomy for distal aortic arch aneurysm in patients aged ≥75 years. METHODS: Patients who underwent d-TEVAR or TAR for aortic arch aneurysm between 2008 and 2015 at our hospital and aged ≥75 years were included. Age, sex, left ventricular ejection fraction, preoperative creatinine level, diabetes, cerebrovascular disease, and chronic obstructive pulmonary disease were matched using PS. RESULTS: Among 74 patients (d-TEVAR: 51, TAR: 23), 17 patients in each group were matched. No difference in surgical outcome was detected between the d-TEVAR and TAR groups, including 30-day death (0% vs. 0%), hospital death (5.8% vs. 0%: p = 0.31) and incidence of cerebral infarction (5.8% vs. 7.6%: p = 0.27) as well as the long-term outcomes of 5-year survival (92.8% vs. 74.8%: p = 0.30) and 5-year aorta-related event-free rate (88.2% vs. 100%: p = 0.15). Average duration of ICU stay (1.3 ± 1.1 days vs. 5.6 ± 1.3 days: p = 0.025) and hospital stay (16.5 ± 5.2 days vs. 37.7 ± 19.6 days: p = 0.017) were significantly shorter in the d-TEVAR group. CONCLUSION: Our results indicated that d-TEVAR is less invasive without affecting long-term outcome up to 5 years. Although the number of the patients included in the study was small, debranching TEVAR could be one of the treatments of the choice in the elderly, especially with comorbidities.

Three-dimensional Camera Imaging in Postoperative Evaluation of Distraction Osteogenesis.

Distraction osteogenesis needs to be regularly assessed in some way to monitor the degree of advancement. X-ray is used for the general evaluation of osteotomy. However, radiation exposure should be avoided. The purpose of this study is to evaluate 3-dimensional (3D) camera imaging for postoperative evaluation. Three patients who underwent Le Fort I or III advancement osteotomy using rigid external distraction and internal distraction were observed in this study. The degrees of the distractions were evaluated using VECTRA H1 3D imaging in addition to computed tomographic (CT) scans. In the VECTRA 3D imaging, the tilt and size of the faces were corrected using the dedicated software for imaging. The preoperative and postoperative images were superimposed, and the distances of motion between the landmarks were measured. In CT scans, the bone distances between osteotomy points of the pterygomaxillary junction were analyzed. As the VECTRA 3D imaging can be compared by overlaying previous photographs, it served as a good tool to evaluate the distractions. However, both the soft-tissue movement measured by VECTRA and CT bony measurements did not match the total amount of movement for the internal distraction devices. The bony advancements were less than the amount of distraction. The soft tissues shrank after the distraction was completed in all cases. Three-dimensional camera imaging is considered to be a useful tool for the evaluation of distraction osteogenesis.

Microsurgical mandibular reconstruction using a resin surgical guide combined with a metal reconstructive plate.

INTRODUCTION: In mandibular reconstruction, repositioning the mandibular position is still challenging and time consuming. We invented a new re-positioning technique using a resin plate combined with a reconstructive plate in reconstructing the mandible with an osteocutaneous free flap. The purpose of this report is to introduce this technique and evaluate the accuracy of mandibular reconstruction using free flaps. We hypothesized that this technique is precise and can reduce intraoperative plate bending at a low cost and short preparation period. METHODS: Mandibular reconstruction was successfully performed in a total of 10 cases without any complications. In this technique, a pre-bent reconstructive plate was prepared in accordance with a three-dimensional model, and then coated with resin. Intraoperatively, the mandibles were secured by fitting these plates snugly and fixing them using a reconstructive plate. Then the resin was removed and free osteocutaneous free flaps were transfer to the defect. Ten patients with a mean age of 68.2 who underwent mandibular resection for aggressive benign (n = 1) or malignant disease (n = 9) were reconstructed using this technique. Seven cases were reconstructed using fibular osteocutaneous free flaps, while scapular osteocutaneous free flaps were used in the remaining cases. The resections entailed: unilateral symphysis and lateral body in four cases, angle to ipsilateral angle in two, ramus to symphysis in two, and lateral body plus angle to symphysis in one case. The deviation of the mandible was evaluated by measuring the preoperative versus postoperative differences in the distances between six bilateral landmarks. RESULTS: There were no complications and flap failure in any of the 10 cases. No further intraoperative plate bending was required. One case underwent additional mucosal resection due to recurrence of cancer. Three cases were referred to postoperative chemoradiotherapy. Two patients expired during follow-up due to recurrence of cancer. Six cases were put back on a normal diet. The other cases who lacked opposing teeth had to remain on a soft diet. The mean follow-up period was 46.2 months. The average of the absolute deviation values was 1.45 mm. This value was 0.94 mm in six cases with mandibular body defects and 2.26 mm in four cases with mandibular defects involving the ramus. CONCLUSIONS: The present novel technique is simple, quick to prepare, and accurate. This technique can be a viable option for microsurgical mandibular reconstruction.