Spatially modulated erbium YAG laser as a treatment for diabetic ulcer.

OBJECTIVE: Diabetic ulcers are a significant healthcare challenge, capable of diminishing quality of life, lengthening hospitalisation stay, and incurring substantial costs for patients and healthcare systems. Erbium-doped yttrium-aluminum-garnet (Er-YAG) laser has been evolving as a prospective intervention for addressing wounds of various aetiologies. Despite this, the literature remains limited in appraising the effectiveness of laser therapy specifically in diabetic wounds. This study investigates the impact of employing a spatially modulated Er-YAG laser as a therapeutic approach for treating diabetic ulcers. METHOD: In a single-arm study conducted from November 2017 to April 2023, patients with hard-to-heal ulcers were treated in a two-step approach of wound debridement using Er-YAG laser for ablation and biostimulation through deep tissue resonance using RecoSMA (Multiline laser system, LINLINE MS, Latvia) laser technology. Ulcers received weekly laser treatment, together with routine care until healing occurred and were then followed up to observe any recurrence. The primary outcome measure was wound closure; the secondary outcome measures were time to closure, and the number of laser treatments required. Data related to sociodemographic details, size and number of diabetic ulcers, and number of sessions related to laser treatment were collected using a predesigned, pretested questionnaire before initiating the treatment. RESULTS: A total of 59 patients attending the clinic during the study period with diabetic ulcers were included in the study. The mean wound surface area at baseline was 25.7cm2 (median: 12cm2). The average number of sessions of laser treatment required was 4.41, ranging from 1-11. The size of the ulcer reduced with each session of laser treatment. The diabetic ulcers healed completely at the end of the treatment, indicating the effectiveness of the Er-YAG/RecoSMA two-step approach. CONCLUSION: Spatially modulated erbium YAG laser is effective as a therapeutic approach for treating diabetic ulcers.

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report.

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC-VLN) flap was used in the management of a 33-year-old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow-up, the IC-VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC-VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow-up are required to analyze the efficacy and long-term results of this flap.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema.

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.

Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema.

Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.

Reconstruction after orbital exenteration using gracilis muscle free flap.

BACKGROUND: Orbital exenteration (OE) is a disfiguring procedure, which typically includes the removal of the entire eyeball including the globe, extraocular muscles, and periorbital soft tissues after malignancies excision or trauma. Several methods of orbital reconstruction have been attempted with varying success. In this report, we analyze results of the use of gracilis muscle free flap for reconstruction of OE defects and its feasibility for prosthetic rehabilitation. METHODS: Nine consecutive patients treated at the China Medical University Hospital of Taichung during January 2009 to January 2013, who had gracilis free flap reconstruction after OEs, were retrospectively reviewed. Cancer in six patients and trauma in remaining three patients was the cause for OE. RESULTS: Nine patients who underwent reconstruction with gracilis free tissue transfer had a successful outcome. There was not any donor or recipient site morbidity; however, one patient was deceased during follow-up period due to metastasis. The mean follow-up period was 23.5 months. Cosmetic results were acceptable both to patients and to surgeons. CONCLUSIONS: Gracilis free flap to repair OE defects may be a safe alternative for reconstruction. It provides a larger volume of well-vascularized tissue, greater placement flexibility, and minor donor site morbidity without any significant functional deficit.

Supraclavicular osteocutaneous free flap: clinical application and surgical details for the reconstruction of composite defects of the nose.

The supraclavicular fasciocutaneous flap is a well-recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm × 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico-periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects.

Severe hidradenitis suppurativa treatment using platelet-rich plasma gel and Hyalomatrix.

Hidradenitis suppurativa (HS) can be a debilitating chronic disease. The underlying cause of the disease is still not clear. HS may be managed through numerous different medical or surgical procedures. Surgical treatment may consist of local excisions and reconstruction using a variety of methods: perforator flaps, skin grafts, local flaps, primary closure or secondary wound healing with vacuum and other devices. This report describes our experience with surgical excision and closure using platelet-rich plasma (PRP) gel and Hyalomatrix PA (HPA) in a patient with severe HS involving most of the body surface. We treated the patient with resection of severe HS of the nuchae and closure with PRP gel prepared with the RegenKit(®) to promote neovascularisation and HPA, a delivery system for hyaluronic acid, to induce a neodermis at the wound bed and to stimulate regeneration in a humid and protected environment. Complete wound healing was achieved after 2 months. The obtained result proved the efficacy of this treatment without complications. No recurrence was observed during the 1 year after the surgical procedure. Severe HS can be safely and effectively managed with wide excision, PRP gel and Hyalomatrix to achieve a successful outcome.

Modified Charles procedure and lymph node flap transfer for advanced lower extremity lymphedema.

INTRODUCTION: Treatment of advanced lymphedema remains a challenge in reconstructive surgery. Microsurgical techniques seem to be effective in early stage lymphedema, however in advanced stages their role is not well established. In this study, we present a novel approach for advanced lymphedema combining excisional procedure (Charles) with transferring lymph node flap. PATIENTS AND METHOD: From 2010 to 2013, 24 patients (18 women, six men, mean age 53 years old) presented with late stage of lower extremity lymphedema. The modification of Charles procedure consisted of preserving the superficial venous system of the dorsum of the foot and the lesser saphenous vein, which were used for the venous anastomosis of the transferred lymph node flap. In 11 patients we transferred the inguinal lymph node flaps from the contralateral site, meanwhile in 13 patients supraclavicular lymph node flaps were used. RESULTS: Maximum reduction of the lymphedema was achieved. No major complication was detected postoperatively. There were two patients with partial loss of the skin graft necessitated re-grafting. All the lymph node flaps survived well. The patients resumed normal daily activities within a period of 2 months. The mean follow-up was 14 months (3-26 months). During this period, no recurrence of the lymphedema was observed. CONCLUSION: The combination of the modified Charles procedure with vascularized transferring of lymph node flap is an effective method for treatment of advanced stage lymphedema.

Novel approach with fractional ultrapulse CO2 laser for the treatment of upper eyelid dermatochalasis and periorbital rejuvenation.

Fractional ultrapulse CO2 laser resurfacing improves photodamage, wrinkles, and acne scarring by ablation of damaged tissue with subsequent regeneration and remodeling of collagen. In this study, the authors examined the efficacy and safety of fractional CO2 laser and introduce a novel approach to the treatment of upper eyelid dermatochalasis. We treated 20 patients with low and moderate upper eyelid dermatochalasis. We did photographic analysis of results by measuring distance of upper eyelid fold and lateral eyebrow in vertical axis from a horizontal line joining medial and lateral canthi. All patients underwent UltraPulse CO2 laser (Microxel MX 7000) resurfacing at upper eyelid, superior to eyebrow, and in periorbital area. Measurements were taken before and at 3 and 6 months after the laser treatment. We evaluated results at 3 and 6 months after laser treatment and found that the UltraPulse CO2 laser induced elevation of eyelid crease and brow position (1.62 ± 0.69 and 2.110 ± 0.66 mm at 3 months; 1.63 ± 0.68 and 2.300 ± 0.67 mm at 6 months, respectively) as compared to before the treatment. Side effects were mild, patients reported minor crusting and oozing that resolved within 48 to 72 h, edema (1-2 days), and moderate postoperative erythema resolved within 4 days. These data illustrate the safety and efficacy of fractional ultrapulse CO2 laser in the treatment of low and moderate upper eyelid dermatochalasis with added advantage of nonsurgical brow lift.

Modified distal anastomosis between colon and thoracic esophagus for hypopharynx reconstruction using free colon flap: A comparison study.

BACKGROUND: Free colon flap is the preferred method of hypopharynx reconstruction when the defect is substantial, or simultaneous voice reconstruction is planned. Most of the complications in free colon flaps are located at the anastomosis between colon and thoracic esophagus due to size mismatch of the lumen. We present our experience comparing a modified anastomosis technique and a conventional anastomosis technique at the distal end of interposed colonic segment. METHODS: In this retrospective review, 94 patients, divided into two groups, underwent hypopharynx reconstruction. Group A (18 patients), conventional anastomoses between colon and thoracic esophagus was performed, while in Group B (76 patients), underwent the modified method of anastomosis. RESULTS: The average follow-up period was 46 months in group A and 54 months in group B. Fistula formation was found in 2 patients from Group A, and 1 patient from Group B. Strictures were observed in 4 patients from Group A, and 1 patient from Group B. Difference between both groups regarding complications of leakage and stricture formation was statistically significant (p < 0.05). CONCLUSION: Modified method for anastomosis between colon and thoracic esophagus was found to be effective in the reduction of complications associated with the use of a free colon flap for hypopharyngeal reconstruction. Further advances of this technique could gain momentum in the future.

Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures.

Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.

Efficacy of a Novel Optimized Pulsed Light Source (MaxG) for the Treatment of Facial Vascular Lesions.

BACKGROUND AND OBJECTIVE: Facial vascular malformations can cause a number of functional problems, including difficulties in breathing, eating, speech, and mobility. Psychological problems can also arise due to the possible unpleasant appearance of such lesions. Further, these lesions can lead to a number of complications, including pain, ulceration, infection, and significant bleeding. Many treatments have been proposed in the literature. Laser therapy (and its related treatments by non-coherent light sources) is now considered the gold standard in the treatment of the majority of vascular lesions. METHODS: Here, we present our experience with a novel optimized pulsed light source for the treatment of vascular anomalies. In this prospective study, we evaluate the clinical outcomes of 30 patients treated with this method. RESULTS: Our results confirm the efficacy and safety of this treatment for facial vascular lesions. CONCLUSIONS: Based on our experience and results, we believe this device could be considered as both an alternative monotherapy and a useful adjunctive to the already existing laser instruments.

Potential Use of Transferred Lymph Nodes as Metastasis Detectors after Tumor Excision.

Due to the fact that it reliably results in positive outcomes, lymph node flap transfer is becoming an increasingly popular surgical procedure for the prevention and treatment of lymphedema. This technique has been shown to stimulate lymphoangiogenesis and restore lymphatic function, as well as decreasing infection rates, minimizing pain, and preventing the recurrence of lymphedema. In this article, we investigate possible additional benefits of lymph node flap transfer, primarily the possibility that sentinel lymph nodes may be used to detect micro-metastasis or in-transit metastasis and may function as an additional lymphatic station after the excision of advanced skin cancer.

Lymphedema fat graft: an ideal filler for facial rejuvenation.

Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.

Periprosthetic atypical mycobacterial infection in breast implants: a new kid on the block!

INTRODUCTION: Breast augmentation is one of the most commonly performed cosmetic surgical procedures. Infection in the breast implant surgery can range from simple wound infection to periprosthetic infection usually with skin commensals such as staphylococci. However, with routine use of broad-spectrum antibiotics atypical mycobacterial infections are being increasingly reported. MATERIAL AND METHODS: We studied 12 cases of atypical mycobacterial breast implant infections over a period of 8 years from 2002 to 2010. Six of them were primarily operated at our centre and six referred from elsewhere after implant infection. Age range was 30-40 years and follow-up after secondary surgery ranged from 1 to 5 years. All patients were explanted and started on combination antibiotics namely, clarithromycin, gatifloxacillin and linezolid for 3 months. After a period of 3 months, all patients underwent implant surgery again with the same antibiotic cover for 6 weeks. RESULT: All the secondary implant augmentations were successful. Organisms grown in primary culture were Mycobacterium fortuitum and M. chelonei. All patients were satisfied with the final breast form and size achieved. CONCLUSION: The possibility of an atypical mycobacterial infection should always be at the back of the mind of an alert surgeon to prevent a periprosthetic infection from compromising the final aesthetic result of a breast implant procedure. Diagnosed early and eradicated in time, the final result is not compromised.