Impact of Magnetic Resonance Lymphography on Lymphaticolvenular Anastomosis for Lower-Limb Lymphedema.

BACKGROUND: Although several investigations have described the safety, utility, and precision of magnetic resonance lymphography (MRL) as a preoperative examination for lymphaticovenular anastomosis (LVA), it is unclear how much MRL assistance impacts LVA results. The present study aimed to clarify the outcome of MRL-assisted LVA for leg lymphedema using body water measurements obtained by bioelectrical impedance analysis. METHODS: The water reductive effect of MRL-assisted LVA in female secondary leg lymphedema patients was compared with that of non-MRL-assisted controls in this retrospective study. In the MRL-assisted group, all LVA candidates underwent MRL prior to surgery, and the lymphatic vessels to be anastomosed were primarily determined by MRL findings. The body water composition of the treated legs was assessed before LVA and at 6 months postoperatively using a multi-frequency bioelectrical impedance analyzer. RESULTS: Twenty-three patients in the MRL-assisted study group and an equal number in the non-MRL-assisted control group were analyzed. Although mean leg water volume before LVA, mean excess water volume of the affected leg before LVA, and number of anastomoses created were comparable between the groups, the water volume reduction (1.02 L versus 0.49 L; 95% confidence interval [CI]: 0.03-1.03, p < 0.05) and edema reduction rate (46.7% versus 27.2%; 95% CI: 3.7-35.5%, p < 0.05) in the MRL-assisted group were significantly greater than in controls. CONCLUSION: Preoperative MRL-assisted lymph vessel visualization and selection appeared to significantly enhance the water reductive effect of LVA for International Society of Lymphology classification stage 2 leg lymphedema. MRL also helped to reliably identify lymphatic vessels for anastomosis. Without increasing the number of anastomoses, LVA could be performed more effectively by better detecting stagnant lymphatic vessels using MRL.

Umbilical shapes predict future protrusion in pediatric umbilical hernias.

BACKGROUND: This study was conducted to evaluate the incidence and early predictive factors of the development of protuberant umbilicus in pediatric umbilical hernia patients. METHODS: In this retrospective visual and chart review, patients younger than 3 months with umbilical hernias who initially visited Ina Central Hospital from April 2011 to March 2017 and were followed until they started to walk (at the age of 1 year) were evaluated. The umbilici of the patients at the age of 1 year were classified into two types based on their appearance: concave and protuberant umbilici. Single-factor and logistic regression analyses of the association between the appearance of the umbilicus at the age of 1 year and various clinical data were performed. RESULTS: Of the 103 patients, 72% had concave umbilici, and 28% had protuberant umbilici. Single-factor analysis showed significant differences in the umbilical shapes at the initial visit (P < 0.001) and straining habit (P < 0.001). The most ideal logistic regression model demonstrated that umbilici of the highly inflated balloon type (odds ratio, 27.00; 95% confidence interval odds ratio, 5.60-130.08) and crescent type (odds ratio, 14.34; 95% confidence interval odds ratio, 4.22-48.77) were more likely to develop into protuberant umbilici. CONCLUSIONS: Umbilical shapes at the initial visit can be used to predict the future development of protuberant umbilici in pediatric patients with umbilical hernias.

Water Reductive Effect of Lymphaticovenular Anastomosis on Upper-Limb Lymphedema: Bioelectrical Impedance Analysis and Comparison with Lower-Limb Lymphedema.

BACKGROUND: We previously examined the water reductive effect of lymphaticovenular anastomosis (LVA) using bioelectrical impedance analysis (BIA) measurement on lower-limb lymphedema and revealed mean water volume reduction and edema reduction rate by leg LVA to be 0.86 L and 45.1%, respectively. This study aimed to clarify the water reductive effect of LVA on arm lymphedema and compare its results with those for leg lymphedema. PATIENTS AND METHODS: The efficacy of LVA for unilateral arm lymphedema was evaluated using BIA in a retrospective cohort. Limb circumference and arm body water volume (ABW) of the affected and unaffected arms were measured before and after LVA. Mean water volume reduction (ΔABW) and edema reduction rate by arm LVA were compared with values for leg LVA cited from our previous report as a historical control. RESULTS: Nineteen consecutive patients were enrolled. The mean ΔABW and edema reduction rate by BIA were 0.267 L and 46.0%, respectively. The decreasing rate of ABW by BIA was significantly larger than those of the upper extremity lymphedema index and sum of 5 circumferences measurement methods. ΔABW could be predicted by a regression line based on the preoperative water volume difference between affected and unaffected limbs. The mean edema reduction rates for arm and leg LVA were comparable. CONCLUSION: The water reductive effect of LVA on upper-limb lymphedema was demonstrated by BIA assessment. BIA can reflect the effect of LVA more sensitively than conventional objective measurements and may facilitate the interpretation of LVA results. Although water volume reduction by arm LVA was less than that by leg LVA, the edema reduction rates were comparable.

Screening for Breast Cancer-Related Lymphedema Development Using Extracellular Water Ratio.

Background: This case-control retrospective study examined whether the extracellular water ratio (%ECW) of the upper extremity, as measured through bioelectrical impedance analysis (BIA), could be an indicator of the development and severity of breast cancer-related lymphedema (BCRL). Methods and Results: BIA was used to evaluate the changes in %ECW due to BCRL development, with the %ECW measured in female patients with unilateral BCRL and healthy controls. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic ability of %ECW to distinguish BCRL patients from controls. Twenty female patients, who were eligible for inclusion, and 20 healthy control volunteers were included. The %ECW of the affected arm correlated with the water volume difference between the affected and unaffected arms (R2 = 0.7183). ROC analysis showed that %ECW had a high diagnostic ability as a screening tool for BCRL development (area under the ROC curve = 0.982). A cutoff %ECW value of 38.5% could predict the presence of BCRL with a sensitivity of 91.7% and specificity of 97.9%. Conclusions: This study confirmed that %ECW could assess the presence and severity of BCRL in a single measurement noninvasively in a shorter amount of time. The %ECW value strongly correlated with excess arm body water volume, an indicator of the severity of unilateral arm lymphedema. The cutoff %ECW value could predict the presence of BCRL with high accuracy.

Changes in intracellular water volume after leg lymphedema onset and lymphaticovenular anastomosis as its surgical intervention.

OBJECTIVE: To clarify the changes in the intracellular water (ICW) volume in lymphedema-affected legs after lymphedema onset and its surgical intervention (ie, lymphaticovenular anastomosis [LVA]), we investigated the changes in body water composition using bioelectrical impedance analysis. METHODS: This retrospective case series included 41 women with unilateral secondary leg lymphedema. The volume changes in the ICW and extracellular water (ECW) of the affected leg were measured using an InBody S10 (InBody Co, Ltd) multifrequency bioelectrical impedance analyzer, at both lymphedema onset and 1 year after LVA. RESULTS: The volume increase with leg lymphedema onset was comparable between the ECW and ICW (0.59 L vs 0.56 L; 95% confidence interval [CI], -0.02 to 0.06; P = .27), and the increase rate was higher for ECW (35.3% vs 22.1%; 95% CI, 9.3%-17.2%; P < .001). The volume reduction at 1 year after LVA was comparable between ECW and ICW (0.23 L vs 0.27 L; 95% CI, -0.08 to 0.02; P = .20), and the reduction rate was higher for ECW (8.7% vs 7.0%, 95% CI, 0.04%-3.2%; P = .044). The volume difference between ICW and ECW remained constant throughout the six measurements before and after LVA (F[3.01, 120.20] = 1.85; P < .14). CONCLUSIONS: Leg LVA reduced ICW in the lymphedematous leg. The onset of leg lymphedema increased ECW and ICW in the affected limb, and LVA decreased both ECW and ICW. The volume change in the affected leg was comparable between ECW and ICW at both lymphedema onset and after LVA. However, the rate of change was higher for ECW. The volume difference between ICW and ECW remained constant. Using bioelectrical impedance analysis, alterations in ICW volume were detected in the legs affected by lymphedema, both after the onset of lymphedema and after LVA intervention.

Magnetic resonance lymphography as three-dimensional navigation for lymphaticovenular anastomosis in patients with leg lymphedema.

BACKGROUND: Precise mapping of functional lymphatic vessels is essential for successful lymphaticovenular anastomosis (LVA). This study aimed to clarify the precision of magnetic resonance lymphography (MRL) in detecting lymphatic vessels prior to LVA. METHODS: Eighteen patients with leg lymphedema were recruited for this prospective study. All patients underwent MRL before LVA to obtain three-dimensional coordinates of lymphatic vessels from MRL images. The precision of MRL for detecting lymphatic vessels was evaluated and compared with those of other contrast techniques. RESULTS: Twenty legs from 18 patients were analyzed. A total of 40 skin incisions were made, 32 of which were determined by MRL. The precision of MRL to detect lymphatic vessels was 94%. With the addition of MRL, the number of lymphatic vessels identified preoperatively was increased as compared with indocyanine green lymphography (ICG-L) alone. Assuming a detection sensitivity of MRL for lymphatic vessels of 1, those of other contrast techniques were 0.90 for ICG-L under microscopy, 0.73 for patent blue staining, and 0.43 for ICG-L before incision. Whereas ICG-L before incision could not detect lymphatic vessels at depths greater than 17.0 mm, all deeper anastomosed lymphatic vessels were identified by MRL. CONCLUSION: Lymphatic vessels enhanced on MRL can be reliably identified intraoperatively. MRL is a promising preoperative examination in LVA that can selectively depict suitable lymphatic vessels even in deep tissue layers.

Aesthetic outcomes following adipose flap versus fillet flap technique for radial polydactyly: a comparison study.

We performed a comparative study looking at the aesthetic outcomes of using a digital artery vascularized adipose flap (DAAF) for treatment of Wassel type IV radial polydactyly versus a fillet flap technique. Clinical charts and pictures of patients between 2002 and 2017 were reviewed to evaluate the appearance of 16 reconstructed thumbs using a visual analogue scale. Our results showed that the DAAF technique resulted in better outcomes with regard to contour of the thumb than the fillet flap group, with significantly less conspicuous scarring in the DAAF group. We conclude that the DAAF can produce better aesthetic outcomes in the reconstruction of radial polydactyly than conventional fillet flaps.Level of evidence: III.

Extracellular Water Ratio as an Indicator of the Development and Severity of Leg Lymphedema Using Bioelectrical Impedance Analysis.

Background: This case-control retrospective study focused on the extracellular water ratio (%ECW) of lymphedemic limbs measured by bioelectrical impedance analysis (BIA) as a possible indicator of the development and severity of unilateral and bilateral leg lymphedema. Methods and Results: BIA was used to evaluate changes in %ECW due to lymphedema in female patients with unilateral secondary leg lymphedema and in healthy controls. Receiver operating characteristic (ROC) analysis was employed to assess the diagnostic ability of %ECW to distinguish leg lymphedema patients from controls. Thirty-eight female patients were eligible for inclusion along with an equal number of healthy control volunteers. The %ECW of the affected leg correlated with leg body water volume (R2 = 0.28) and the water volume difference between affected and unaffected legs (R2 = 0.58). The ROC analysis showed that %ECW had a high diagnostic ability as a screening tool for the development of leg lymphedema (area under the ROC curve = 0.96). A cutoff %ECW value of 40.0% could predict the presence of leg lymphedema with a sensitivity of 81.6% and specificity of 97.4%. Conclusions: %ECW value may be a simple and useful indicator of the development and severity of leg lymphedema. As a screening test, %ECW measurement can predict the presence of unilateral or bilateral leg lymphedema in a single measurement without the need for arm, contralateral leg, or previous measurements as controls.

Reimplantation of a Pacemaker into a Subpectoral Pocket Via the Lateral Approach in Collaboration with Plastic Surgeons.

An 86-year-old woman had a pacemaker implanted into a subfascial pocket. After four months, the generator became exposed, and the pacemaker was removed. She exhibited a lack of prepectoral tissue. We therefore performed reimplantation in collaboration with plastic surgeons. We placed the leads via the extrathoracic subclavian venous approach, and plastic surgeons created a subpectoral pocket from the low lateral side of the pectoralis major muscle. General cardiologists rarely create subpectoral pockets and they are unable to implant leadless pacemakers at their hospital due to lack of sufficient skill. Our case showed that creating a subpectoral pocket in collaboration with plastic surgeons is quick and safe.

Differences in palpebral fissure height depending on patient's intraoperative head position.

BACKGROUND: Blepharoptosis operations are performed under local anaesthesia, and it is necessary to determine the location where the levator aponeurosis is fixed to the tarsus by checking opening and closing of the eyelids during surgery. Changes in posture during the operation affect the facial condition in various ways. This study was performed to clarify the differences in palpebral fissure height according to intraoperative head position. METHODS: Sixty subjects (48 women and 12 men aged 20-76 years) were enrolled in the study. The palpebral fissure height of the dominant eye was measured in the head-neutral position and 30° head-down position. RESULTS: The total fissure height in the 30° head-down position was lower than that in the head-neutral position. CONCLUSIONS: The head-down position affects the patient's fissure height and may mislead the operator. Blepharoptosis operation under local anaesthesia should be performed with the patient in the head-neutral position.

Three-Dimensional Simulation for Breast Augmentation of Female Asymmetric Pectus Excavatum: A Case Report.

Breast augmentation for women with asymmetric pectus excavatum (PE) has a characteristic problem in that surgeons need to select implants while considering the left-right difference in breast volume, contour, and position. We herein report a 33-year-old woman with severe asymmetric PE who presented with residual breast asymmetry after chest wall correction using the Nuss procedure. Her right breast appeared hypoplastic and the right anterior chest wall remained depressed. Augmentation of the right breast with a silicone implant was performed, selecting the inserted implant preoperatively with the assistance of three-dimensional (3D) simulation. The breast asymmetry and anterior chest wall depression were improved to a natural appearance. Three-dimensional simulation represents an advantageous way to preoperatively select optimal implants for breast augmentation in asymmetric PE women with breast asymmetry.

Convex bone deformity after closed reduction of nasal bone fracture.

BACKGROUND: Nasal fracture is the most common type of facial fracture treated by plastic surgeons. Here, we clarify the postoperative deformities that frequently remain after closed reduction of fresh nasal bone fracture by three-dimensional computed tomography (3D-CT). METHODS: Hundred consecutive cases of fresh nasal bone fracture in patients treated between May 2010 and January 2016 were examined. After closed reduction, the overall appearance of the arch formed by the nasal bone and maxillary process was evaluated as 'Excellent', 'Good' or 'Fair'. Patients were also asked about their overall satisfaction with the operation, and the responses were classified as 'Satisfied', 'Neutral' or 'Dissatisfied'. RESULTS: Eighty-six patients underwent 3D-CT examination both at the time of the initial consultation and 3 months after the operation. The results were 'Excellent' in 69 patients and 'Good' in 17 patients, with none of the patients having only 'Fair' results. Convex bone deformities on one side were seen in all six bilateral type fractures evaluated as 'Good'. All patients classified as 'Excellent' reported being 'Satisfied' with the results, but some patients classified as 'Good' gave a 'Neutral' evaluation regarding their satisfaction. CONCLUSIONS: The residual deformities seen in bilateral type fractures were most notable, and they were all convex bone deformities on one side. Plastic surgeons should use ultrasonography or other reliable new methods in addition to visual inspection during the operation to successfully treat the region of the convex fracture.

A new percutaneous method for inframammary fold reconstruction in implant-based breast reconstruction: Vertical pendulum suture.

Several operative techniques for inframammary fold (IMF) reconstruction have been described and have resolved the shortcomings of conventional methods. However, there are still difficulties with IMF reconstruction, that is, performance through small mastectomy scars, creation of a smooth IMF curve, transfer of external IMF markings to the interior chest wall, or determining correct IMF without an implant in place. We have used a type of anchor suture with a completely percutaneous approach, the vertical pendulum suture (VP suture), to reconstruct the IMF easily in implant-based breast reconstruction.The VP suture requires a pair of skin incisions a few millimeters in length (incisions A and B). The needle passes through the subcutaneous tissue from incision A, the chest wall, again through the subcutaneous tissue, and exits from incision B. Then, the needle passes through the edge of the dermis from incision B, the superficial layer of the subcutaneous tissue, again through the other edge of the dermis, and exits from incision A. The knot is tied and buried in the subcutaneous tissue. The whole technique can be performed percutaneously without visualizing the inside of the pocket. A retrospective case series study of photographs and chart review was conducted for all cases of unilateral implant-based breast reconstruction performed from December 2016 to December 2017 at Ina Central Hospital, Ina, Japan.Nine consecutive patients underwent unilateral implant-based breast reconstruction. Five patients treated using the VP suture were included in this study. All 5 patients showed good esthetic results over the follow-up period (average, 11 months). Scalloped appearance was observed in all patients, but flattened spontaneously and disappeared within 3 months postoperatively. There were no complications, such as hematoma, infection, skin necrosis, pneumothorax, seroma, scar contracture, or implant injury.The VP suture is completely percutaneous, parallel to the IMF, and is easy to perform at any time during surgery regardless of whether the implant is in place or not. IMF reconstruction is facilitated by freeing the surgeon from the need to visualize the inside of the pocket.

A simple and safe technique for manipulation of retrosternal dissection in the nuss procedure.

OBJECTIVE: The Nuss procedure has become the first choice for repairing the pectus excavatum because of the advantages of the technique including minimal invasiveness and short operative duration. Although this technique appears simple and easy, life-threatening complications during dissection such as intraoperative cardiac perforation have been reported. We developed a new approach for safer dissection of retrosternal space. METHODS: We use a dissector that is commonly used for laparoscopic operation, instead of the Nuss introducer. The dissector goes through the same skin incision where the Nuss bar will be inserted. The major difference is the position of dissector insertion, which is set up more dorsally than usual, and the use of a laparoscopic dissector instead of the Nuss introducer. In this new approach, the direction of dissection is from dorsal toward the anterior thoracic wall, which allows us to visually follow the tip of the dissector throughout the surgery. Moreover using the dissector that has better manipulation capability enables us the fine dissection and also is able to precisely determine both the layer and the area of the dissection level. RESULTS: We have treated more than 150 patients using this technique without any complications since 2008. In all the cases, safer dissection of the retrosternal space was performed with good results. CONCLUSION: We believe every surgeon can easily apply this procedure to patients with pectus excavatum, and this procedure can reduce the stress during the dissection.

Pathogenesis and surgical correction of involuntary contraction of the occipitofrontalis muscle that causes forehead wrinkles.

Assuming that an agonistic function is present to maintain an adequate visual field, we hypothesized that stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the occipitofrontalis muscle, as well as the levator muscles. In patients with aponeurotic blepharoptosis, both unilateral instillation of phenylephrine to contact Mueller smooth muscle fibers and unilateral aponeurotic fixation ipsilaterally reduced the eyebrow height during primary and upward gazing. Bilateral aponeurotic fixation bilaterally reduced the eyebrow height, with fewer forehead wrinkles. Stretching of the mechanoreceptor of Mueller muscle induces involuntary contraction of the bilateral levator muscles. Its increased stretching may induce involuntary contraction of the ipsilateral occipitofrontalis muscle via the mesencephalic trigeminal nucleus and the facial subnucleus as another stretch reflex. The involuntary contraction of the occipitofrontalis muscle that causes forehead wrinkles during primary gazing can be corrected by the aponeurotic fixation to reduce the stretching of Mueller muscle.

Risk factors contributing to hepatic artery thrombosis following living-donor liver transplantation.

BACKGROUND/PURPOSE: This study was carried out to investigate the risk factors contributing to hepatic artery thrombosis in living-donor liver transplantation. METHODS: Two hundred and twenty-two recipients (113 adults and 109 children) of living-donor liver transplantation were the subjects of this study. The diagnosis of hepatic artery thrombosis was made by color-Doppler ultrasonography and/or hepatic angiography. Parameters for this study were: (1) donor sex, age, and body weight; (2) recipient sex, age, body weight, liver disease, preoperative prothrombin time, and type of arterial reconstruction; and (3) previous liver transplantation. RESULTS: Hepatic artery thrombosis occurred in 12 patients (5.4%) at 3 to 15 days posttransplant. Recipient female sex and metabolic disorder as the original disease were found to be significantly associated with hepatic artery thrombosis. The 5-year patient survival rate in recipients with hepatic artery thrombosis (58.3%) was significantly lower than that in recipients without this complication (84.4%). CONCLUSIONS: Female sex and metabolic disease may be factors contributing to hepatic artery thrombosis after living-donor liver transplantation. More intensive anticoagulation therapy for this patient population might decrease the incidence of hepatic artery thrombosis and, thus, posttransplant recipient mortality.

Pathogenesis and surgical correction of dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus.

The purpose of this study was to confirm whether lower scleral show is caused by the disinsertion of the levator aponeurosis from the tarsus. Aponeurotic advancement by vascular clips or by surgery involving the orbital septum significantly lowered the global position in the orbit and significantly diminished the degree of retraction of the lower eyelid, resulting in satisfactory improvement of lower scleral show in 100 patients with various aponeurotic blepharoptosis. Therefore, we propose the pathogenesis of lower scleral show as follows: additional contraction of the levator muscle to compensate for the disinsertion of the levator aponeurosis from the tarsus for maintenance of an adequate visual field is accompanied by additional contraction of the superior rectus muscle through the strong intermuscular fascia, resulting in upward rotation of the globe. To maintain the horizontal visual axis and foveation without inclination of the head in the primary gaze position, additional contraction of the inferior rectus muscle is induced, which pulls upon the inferior suspensory ligament of Lockwood and the capsulopalpebral fascia. The former displaces the globe upwards and the latter retracts the lower eyelid, resulting in dynamic lower scleral show as a sign of disinsertion of the levator aponeurosis from the tarsus, which can be surgically corrected.

Tracheal reconstruction with a prefabricated deltopectoral flap combined with costal cartilage graft and palatal mucosal graft.

We have created an alternative method for tracheal reconstruction. Our new surgical procedure using a deltopectoral flap combined with a costal cartilage graft and mucosal graft for tracheal reconstruction allows us to achieve reconstruction of the tracheal mucosa, the tracheal cartilage, and the covering skin with adequate subcutaneous tissue. In one case, a tracheostenosis was reconstructed with a deltopectoral flap combined with a costal cartilage graft. In the other case, a tracheal defect was reconstructed with a deltopectoral flap combined with a costal cartilage graft and palatal mucosal graft. Although the operation is a multistage procedure, our method provides satisfactory clinical results. Thus, we believe that our method is useful for the surgical treatment of large tracheal defects.

Dressing for alveolopalatal wounds after alveolar bone grafting.

Cotton gauze with alpha cyanoacrylate was used for alveolopalatal wound dressing after alveolar bone grafting to treat 93 alveolar clefts in 74 cleft patients to reduce mechanical injuries, tension for wound dehiscence, and adhesion of food remnants. T-shaped cotton gauze was put on the gingivoperiosteal flaps and was impregnated with cyanoacrylate. The procedure required no preoperative preparation and its intraoperative execution took less than 5 minutes. The gauze with cyanoacrylate was removed approximately 1 week after surgery. No infection was observed at any of the operational sites, but tiny fistulas developed at four of them. The mean bone graft score was 1.4 point. No complications such as thermal injury resulted from the use of cyanoacrylate. Gauze impregnated with cyanoacrylate proved to be a convenient and dependable dressing for alveolopalatal wounds resulting from gingivoperiosteoplasty for alveolar bone grafting.