Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

Retroauricular lymph node flap: An anatomic and surgical feasibility study.

BACKGROUND: The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS: Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS: The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS: The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.

Selective ansa cervicalis nerve transfer to the marginal mandibular nerve for lower lip reanimation: An anatomical study in cadavers and a case report.

BACKGROUND: Donor nerve options for lower lip reanimation are limited in patients undergoing oncological resection of the facial nerve. The ansa cervicalis nerve (ACN) is an advantageously situated donor with great potential but has not been examined in detail. In the current study, the anatomical technical feasibility of selective ACN to marginal mandibular nerve (MMN) transfer for restoration of lower lip tone and symmetry was explored. A clinical case is presented. METHODS: Dissections were conducted in 21 hemifaces in non-embalmed human cadavers. The maximal harvestable length of ACN was measured and transfer to MMN was simulated. A 28-year-old male underwent ACN-MMN transfer after parotidectomy (carcinoma) and was evaluated 12 months post-operatively (modified Terzis' Lower Lip Grading Scale [25 observers] and photogrammetry). RESULTS: The harvestable length of ACN was 100 ± 12 mm. A clinically significant anatomical variant ("short ansa") was present in 33% of cases (length: 37 ± 12 mm). Tensionless coaptation was possible in all cases only when using a modification of the surgical technique in "short ansa" cases (using an infrahyoid muscle nerve branch as an extension). The post-operative course of the clinical case was uneventful without complications, with improvement in tone, symmetry, and function at the lower lip at 12-month post-operative follow-up. CONCLUSIONS: Selective ACN-MMN nerve transfer is anatomically feasible in facial paralysis following oncological ablative procedures. It allows direct nerve coaptation without significant donor site morbidity. The clinical case showed good outcomes 12 months post-operatively. A strategy when encountering the "short ansa" anatomical variant in clinical cases is proposed.

Imaging Modalities for Evaluating Lymphedema.

Lymphedema is a progressive condition. Its therapy aims to reduce edema, prevent its progression, and provide psychosocial aid. Nonsurgical treatment in advanced stages is mostly insufficient. Therefore-in many cases-surgical procedures, such as to restore lymph flow or excise lymphedema tissues, are the only ways to improve patients' quality of life. Imaging modalities: Lymphoscintigraphy (LS), near-infrared fluorescent (NIRF) imaging-also termed indocyanine green (ICG) lymphography (ICG-L)-ultrasonography (US), magnetic resonance lymphangiography (MRL), computed tomography (CT), photoacoustic imaging (PAI), and optical coherence tomography (OCT) are standardized techniques, which can be utilized in lymphedema diagnosis, staging, treatment, and follow-up. Conclusions: The combined use of these imaging modalities and self-assessment questionnaires deliver objective parameters for choosing the most suitable surgical therapy and achieving the best possible postoperative outcome.

Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysis.

BACKGROUND: Preoperative mapping of lymphatic vessels for lymphovenous anastomosis (LVA) surgery is frequently performed by indocyanine green (ICG) lymphography solely; however, other imaging modalities, such as ultrasound (US), might be more efficient, particularly for Caucasian patients. We present our preoperative assessment protocol, experience, and approach of using US for locating optimal LVA sites. METHODS: Fifty-six (16 males) lymphedema patients who underwent LVA surgery were included in this study, 5 of whom received two LVA operations. In total, 61 LVA procedures with 233 dissected lymphatic vessels were evaluated. Preoperative US was performed by the author S.M. 2 days before intraoperative ICG lymphography. Fluid-predominant lymphedema regions were scanned more profoundly. Skin incisions followed preoperative US and ICG lymphography markings. Detection of lymphatic vessels was compared between ICG lymphography and the US by using the intraoperative verification under the microscope with 20 to 50x magnification as the reference standard. RESULTS: Among the dissected lymphatic vessels, 83.3% could be localized by US, and 70% were detectable exclusively by it. In all, 7.2% of US-detected lymphatic vessels could not be found and verified intraoperatively. Among the lymphatic vessels found by US, only 16% were apparent with ICG before skin incision. In total, 23.2% of the dissected lymphatic vessels could be visualized with ICG lymphography preoperatively. Only 9.9% of the lymphatic vessels could be found by ICG alone. CONCLUSION: High-frequency US mapping accurately finds functional lymphatic vessels and matching veins. It locates fluid-predominant regions for targeted LVA surgeries. It reveals 3.6 times as many lymphatic vessels as ICG lymphography. In our practice, it has an integral role in planning LVA procedures.

Anatomical Features in Lower-Lip Depressor Muscles for Optimization of Myectomies in Marginal Mandibular Nerve Palsy.

INTRODUCTION: Myectomies of the lower-lip depressor muscles, with the aim to improve facial balance in unilateral facial paralysis, have unexplained high recurrence rates. A potential explanation is that these recurrences are due to inadequate resection through the muscle width, leaving lateral muscle fibers intact. AIM: Revisit the anatomy of the lower-lip depressor muscles and suggest an optimization of the surgical technique. Perform a literature review to identify recurrence rates and surgical technique of the procedure. MATERIALS AND METHODS: Ten fresh hemifaces were dissected. The following measurements of depressor labii inferioris and depressor anguli oris were made: the widths of the muscles, the distance from the mandibular midline to the lateral borders of the muscles, and the intraoral distance from the lateral canine to the lateral border of depressor anguli oris. A literature review was performed. RESULTS: The width of depressor labii inferioris was 20 ±â€Š4 mm and depressor anguli oris 14 ±â€Š3 mm. The distance from the midline to the lateral border of depressor labii inferioris was 32 ±â€Š4 mm and 54 ±â€Š4 mm for depressor anguli oris. The literature review revealed a mean recurrence rate of 21%. DISCUSSION: A potential optimization of the surgical technique in lower-lip depressor myectomies is to extend the muscle resection laterally. To ensure inclusion of the whole width of the depressor muscles and decrease the recurrence rates of the procedure, the measurements presented in this study should be kept in mind during surgery.

Exclusive use of ultrasound for locating optimal LVA sites-A descriptive data analysis.

BACKGROUND: The current standard to locate lymphatic vessels for lymphovenous anastomosis (LVA) is the use of indocyanine green (ICG)-lymphangiography. Due to fluid retention and fibrosis of tissue in patients with lymphedema, often present in Caucasian patients, vessels deeper than 0.5 cm below the dermis cannot be visualized. We present our experiences with ultrasound in locating deeper lymphatic vessels in lower extremities. MATERIALS AND METHODS: In total, 28 patients with lymphedema and positive lymphoscintigraphy were included. With ultrasound, we located 82 lymphatic vessels in lower extremities preoperatively without the use of ICG marking. Vessel diameter, depth, and exact location were examined. Using a coordinate system, a mapping of the detected lymphatic vessels was created. The ultrasound findings were confirmed under microscope and ICG intraoperatively. RESULTS: In all, we detected 28 Caucasian patients and 82 lymphatic vessels with ultrasound preoperatively. On average, we found three lymphatic vessels (range, 2-6) at each patient. Of the ultrasound-detected lymphatic vessels, 90.2% could be verified intraoperatively under a microscope. Before skin incision, lymphatic vessels could be visualized in 40% of our patients with ICG. In the mapping of the lymphatic vessels, we found no significant pattern. CONCLUSION: Ultrasound can precisely detect lymphatic vessels for efficient LVA operation without the prior use of ICG-lymphangiography.

Institutionalization of reconstructive lymphedema surgery in Austria-Single center experience.

BACKGROUND: Lymphedema surgery was not widely known in Austria before the introduction of lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in 2014. This study shares the experience and process of establishing and institutionalizing lymphedema surgery service in Austria. METHODS: The purpose of introducing reconstructive lymphedema surgery in Austria was to improve lymphedema patients' quality of life and provide them surgical therapy as an adjuvant treatment to complete decongestive therapy. To initialize reconstructive lymphedema surgery in Austria, LVA and VLNT had to be presented and introduced, in the manner of branding and advertizing a new product. Surgeries were performed with quality control by standardized documentation, pre- and postoperatively. RESULTS: Aligned with branding and marketing, presentations were given externally and internally to share knowledge and experience of lymphedema surgery. Lymphedema surgery service was introduced as a new brand in the medical service in Austria. After several communications with the Austrian Health Insurance Fund and with the final application, LVA and VLNT were listed as novel surgical therapies in its 2020 reimbursement catalog. Since 2014, more than 300 lymphedema patients were consulted, and 102 reconstructive lymphedema surgeries were performed. Circumference reduction of extremities after surgery was between 20% and 43%, postoperatively. CONCLUSION: Acceptance of surgery in lymphedema patients varies among continents, hospitals, and surgeons. Evaluation of the requirement of the surgical setup and insurance conditions for lymphedema surgery is essential to establish lymphedema surgery, providing targeted marketing and branding to spread knowledge of the novel technique and grant patients access to therapeutic treatment of their chronic disease.

Functional results after facial reanimation in iatrogenic facial palsy.

BACKGROUND: Iatrogenic facial nerve injury is a common cause of long-standing facial palsy. This study aimed to assess functional results after facial reanimation in iatrogenic facial palsy and to determine correlating patient factors. METHODS: The data of 128 iatrogenic facial palsy patients were analyzed for this case series. Inclusion criteria for assessment of facial function by three-dimensional video analysis were preoperative and postoperative (>18 months) video sets for facial marker tracking, which were available in 63 patients. Demographic factors and treatment concepts were analyzed and correlations to functional outcomes calculated. RESULTS: One hundred and twenty-eight patients with iatrogenic facial palsy underwent facial reanimation procedures and were included in this study. The mean duration of facial palsy was 7.8 years. The most common procedures leading to iatrogenic facial palsy were acoustic neuroma resection (29.7%), parotidectomy (21.1%), and brainstem/cerebellopontine angle tumor resection (21.1%). Selected functional results were significantly improved after facial reanimation surgery. The mean lagophthalmos during eyelid closure reduced from 7.3 ± 4.1 mm to 5.4 ± 4 mm (p < .001). The function of the mouth was significantly improved, both statically (static asymmetry: 10.3 ± 7.6 mm preoperatively, 0.8 ± 9.5 mm postoperatively; p < .001), and during smile movement ("Dynamic Symmetry Index": 0.16 preoperatively, 0.39 postoperatively; p < .001). The mean duration of facial palsy correlated with postoperative smiling function (r = .358, p = .011). CONCLUSION: Facial reanimation significantly improves facial function in iatrogenic facial palsy. Early referral to a facial nerve center is crucial as duration of facial palsy influences functional outcomes.

The correlation of the perforators and the accessory saphenous vein in a profunda femoris artery perforator flap for additional venous anastomosis: A cadaveric study and clinical application.

BACKGROUND: The profunda femoris artery perforator (PAP) flap is gaining popularity in microsurgical reconstruction. To establish a safer flap elevation technique, we focused on the topology of the accessory saphenous vein in the medial thigh area. We hypothesize that including the accessory saphenous vein in a PAP flap results in safer PAP flap transfer with two venous drainage systems. The aim of this study was to describe the anatomical relationship between the perforators and the accessory saphenous vein in the PAP flap using fresh cadavers and to describe the relationship through two clinical cases. METHODS: For the anatomical study, 19 posterior medial thigh regions from 10 fresh cadavers were dissected. We recorded the number, site of origin, the length, and the diameter of the pedicle. We also documented the course, the length, and the diameter of the accessory saphenous vein. PAP flap transfer with additional accessory saphenous vein anastomosis was performed in two clinical cases; a 40-year-old female with tongue cancer and a 51-year-old female with breast cancer. RESULTS: In all cadaveric specimens, the accessory saphenous vein was found above the deep fascia. The average distance between the proximal thigh crease and the intersection of the anterior edge of the gracilis muscle and the accessory saphenous vein was 7.7 ± 2.5 cm. The diameter of the accessory saphenous vein averaged 3.1 ± 1.1 mm. The average accessory saphenous vein length from its takeoff from the great saphenous vein to the anterior edge of the gracilis muscle was 4.2 ± 1.3 cm. In clinical cases, the flap size was 6 x 18 cm and 8 x 21 cm and the follow-up length was 12 and 3 months, respectively. In both cases, the postoperative course was uneventful and the flap survived completely. CONCLUSION: Anatomical study confirmed that the accessory saphenous vein did exist in all specimens and it could be included in the PAP flap with sufficient length and relatively large diameter. Although further clinical investigation will be required to confirm its efficacy, a PAP flap including the accessory saphenous vein may decrease the chances of flap congestion.

Oculo-zygomatic nerve transfer for facial synkinesis: An anatomical feasibility study.

BACKGROUND: Patients with severe oro-ocular synkinesis often present with concomitant inefficient smile excursion on the affected site. In theory, oculo-zygomatic nerve transfer may decrease synkinesis and improve smile by redirecting nerve fibers to their target muscle. The aim of this study was to explore the feasibility of nerve transfer in human cadavers between a caudal branch innervating the orbicularis oculi to a cephalad branch innervating the zygomaticus major muscles. METHODS: Eighteen hemi-faces were dissected. Reach for direct coaptation of a caudal nerve branch innervating the orbicularis oculi muscle to a cephalad nerve branch innervating the zygomaticus major muscle was assessed. Measurements included total number of nerve branches as well as maximum dissection length. Nerve samples were taken from both branches at the site of coaptation and histomorphometric analysis for axonal count was performed. RESULTS: The number of sub-branches to the orbicularis oculi muscle was 3.1 ± 1.0 and to the zygomaticus major muscle 4.7 ± 1.2. The maximal length of dissection of the caudal nerve branch to the orbicularis oculi muscle was 28.3 ± 7.3 mm and for the cranial nerve branch to the zygomaticus major muscle 23.8 ± 6.5 mm. Transection and tension-free coaptation was possible in all cases but one. The average myelinated fiber counts per mm2 was of 5,173 ± 2,293 for the caudal orbicularis oculi branch and 5,256 ± 1,774 for the cephalad zygomaticus major branch. CONCLUSION: Oculo-zygomatic nerve transfer is an anatomically feasible procedure. The clinical value of this procedure, however, remains to be proven.

Use of the transverse branch of the superficial circumflex iliac artery as a landmark facilitating identification and dissection of the deep branch of the superficial circumflex iliac artery for free flap pedicle: Anatomical study and clinical applications.

BACKGROUND: The deep branch of the superficial circumflex iliac artery (SCIA) should be included when a large superficial circumflex iliac artery perforator (SCIP) flap is necessary, or when anatomical structures perfused by the deep branch are procured. The aim of this study was first to describe the anatomical features of the "transverse branch" of the deep branch of the SCIA in cadavers, and then to assess the efficacy of its use as a landmark for identification and dissection of the deep branch of the SCIA through clinical applications. METHODS: Twenty groin regions from 10 cadavers were dissected. The course and the takeoff point of the transverse branch were documented. With the transverse branch used as a landmark for pedicle dissection, 27 patients (16 males and 11 females) with an average age of 51.7 years underwent reconstructions that used vascularized structures nourished by the deep branch of the SCIA. Aside from the skin paddle, an iliac bone flap was used in 10 cases, a lateral femoral cutaneous nerve flap in four cases, and a sartorius muscle flap in three cases. The defect locations included the head (seven cases), the foot (six cases), the hand (six cases), the arm (five cases), and the leg (three cases). The causes of reconstruction were tumors in 13 patients, trauma in six patients, infection in four patients, surgical procedures in three patients, and refractory ulcer in one patient. RESULTS: In all specimens, the transverse branch was found underneath the deep fascia caudal to the anterior superior iliac spine (ASIS). The average distance from the ASIS to the transverse branch was 25.5 ± 13.0 mm (range, 5-50 mm). The average dimension of the flap was 13.1 × 5.9 cm2 . All the flaps survived completely after the surgery; lymphorrhea was seen in one patient at the donor site. The average follow-up period was 12.9 months (range, from 2 to 42 months), and all patients had good functional recovery with satisfactory esthetic results. CONCLUSIONS: The transverse branch was found in all specimens, branching from the deep branch of the SCIA. Successful results were achieved by using it as the landmark for identification and dissection of the deep branch of the SCIA. This method allows safe elevation of a large SCIP flap or a chimeric SCIP flap.

Contemporary Concepts of Primary Dynamic Facial Nerve Reconstruction in the Oncologic Patient.

Transection of the facial nerve and its branches during extensive ablative procedures in the oncologic patient causes loss of control of facial mimetic muscles with severe functional and aesthetic sequelae. In such patients with advanced tumorous disease, copious comorbidities, and poor prognosis, rehabilitation of the facial nerve has long been considered of secondary priority. However, recent advances in primary facial nerve reconstruction after extensive resection demonstrated encouraging results focusing on rapid and reliable restoration of facial functions. The authors summarize 3 innovative approaches of primary dynamic facial nerve reconstruction by using vascularized nerve grafts, dual innervation concepts, and intra-facial nerve transfers.

Anatomical Study of a Chimeric Fascio-Osteomyocutaneous Fibula Flap for Free Microvascular Tissue Transfer.

BACKGROUND: Functional restoration in reconstructive surgery can require complex and adaptable approaches. In this anatomical study, the combined angiosome of the septofasciomyocutaneous vessels originating from the fibular artery was defined as basis for a chimeric flap of the lateral lower leg. METHODS: Methylene blue injection into the fibular artery was performed in 10 legs of fresh cadavers for visualization of the angiosome on the skin, fibula, and adjacent muscles as the lateral hemisoleus (HS) muscle. With regards to clinical specifications a maximum-size flap containing cutaneous, osseous, and muscular elements was raised. During dissection, the distribution pattern, number and size of stained septofasciomyocutaneous vessels at the lateral border of the proximal, middle, and distal thirds of the fibula length, as well as the flap dimensions were evaluated. RESULTS: In all specimens, vessels originating from the fibular artery and supplying the resected fibular bone, the fasciocutaneous flap and dorsally located muscles were found. The mean number of vessels to the skin was 4.2 per leg with a mean diameter of 1.1 ± 0.5 mm (range: 0.4-2.5 mm) and to the HS muscle 3.4 vessels with a mean diameter of 1.2 ± 0.7 mm (range: 0.3-3.0 mm). A total of 88.4% vessels occurred in the proximal and middle thirds of the legs. The resected fibula graft had a mean length of 23.8 ± 3.9 cm (range: 19.9-31.0 cm) and the skin paddle had a mean size of 23.8 ± 3.9 cm (range: 19.9-31.0 cm) × 7.0 cm. The flexor hallucis longus (FHL) muscle had a mean volume of 37.2 ± 15.8 cm3 (range: 18-58 cm3) and the lateral HS muscle 77.1 ± 23.3 cm3 (range: 48-105 cm3). CONCLUSION: Our results and anatomical descriptions indicate that chimeric fibula flaps can meet the specific reconstructional requirements of complex and large sized defects representing a promising basis for further studies.

The dermal arteries in the cutaneous angiosome of the descending genicular artery.

Studies examining thick skin of the thumb pad have challenged the existence of an arterial plexus in the papillary dermis. Instead of a plexus, discrete arterial units, interconnected by arterio-arterial anastomoses, were identified. We hypothesise that the dermal arteries of thin skin are arranged likewise and that there are fewer arterio-arterial anastomoses in the centre of an angiosome than in zones where neighbouring angiosomes overlap. To test these hypotheses, we examined the dermal arteries in the centre of the cutaneous angiosome of the descending genicular artery (DGA) and its zone of overlap with neighbouring angiosomes. Using traditional perfusion techniques, the cutaneous angiosomes of the DGA and the popliteal artery were identified in 11 fresh frozen human lower limbs. Biopsies were harvested from the centre of the cutaneous DGA angiosome and from the zone where neighbouring vascular territories overlapped. Employing high-resolution episcopic microscopy (HREM), digital volume data were generated and the dermal arteries were three-dimensionally reconstructed and examined. In all examined skin areas, the dermal arteries showed tree-like ramifications. The branches of the dermal arteries were connected on average by 1.73 ± 1.01 arterio-arterial anastomoses in the centre of the DGA angiosome and by 3.27 ± 1.27 in the zone where angiosomes overlapped. We demonstrate that discrete but overlapping dermal arterial units with a mean dimension of 1.62 ± 1.34 and 1.80 ± 1.56 mm2 , respectively, supply oxygen and nutrients to the superficial dermis and epidermis of the thin skin of the medial femur. This forms the basis for diagnosing and researching skin pathologies.

First Experiences with Incisional Negative Pressure Wound Therapy in a High-Risk Poststernotomy Patient Population treated with Pectoralis Major Muscle Flap for Deep Sternal Wound Infection.

BACKGROUND: Radical debridement and wound closure with vascularized flaps has become a standard procedure in the treatment of deep sternal wound infections. Negative pressure incision management systems have been proven to diminish wound infections after sternotomy. In this study, the utility of Prevena Incision Management System (KCI Licensing Inc.) was evaluated in obese patients who received unilateral pectoralis major flap for the treatment of deep sternal wound infections. METHODS: The outcome and wound-related complication rates of 19 obese patients (mean body mass index, 33.7) treated for deep sternal wound infection with pectoralis major muscle flap in combination with Prevena between 2011 and 2016 were compared with 28 obese patients treated with conventional wound dressing only between 2000 and 2010. RESULTS: In patients additionally treated with Prevena, significantly fewer surgical revisions due to wound-related complications were necessary as compared with patients who received conventional wound dressing (5.3 vs. 32.1%, p = 0.034). A significantly shorter ICU length of stay (median 0 vs. 3.5 days, p < 0.001) and a trend toward shorter length of hospitalization (median 14 vs. 19.5 days after pectoralis major flap) could be observed. CONCLUSION: The application of Prevena significantly reduced revision surgery rates in obese patients treated with unilateral pectoralis major flap for deep sternal wound infections.

Use of Social Media and an Online Survey to Discuss Complex Reconstructive Surgery: A Case of Upper Lip Reconstruction with 402 Responses from International Microsurgeons.

BACKGROUND: The best reconstructive strategy for upper lip defects is still in debate. The purpose of this study was to analyze the decisions made by international microsurgeons, who were participated through online questionnaire, distributed by email and social media network. MATERIALS AND METHODS: A case of a two-thirds upper lip oncologic defect was presented via an online questionnaire and 402 microsurgeons replied their treatment options. The data were then analyzed according to the geographic area, microsurgical fellowship, seniority, and subspecialty. All the data were analyzed using SPSS 22. RESULTS: A total of 27.7% of microsurgeons chose a free flap, while 72.3% chose a local/pedicle flap as their preferred method for reconstruction. The most common choice of free and local/pedicle flaps was radial forearm (73.6%) and Abbé (36.2%), respectively. The microsurgeons in Europe preferred local/pedicle flaps than free flap when compared with Middle/South America, Asia-Pacific, Africa and South Asia/Middle East (11.6% versus 50%, 43.4%, 29.3% and 27.3%, respectively, multivariant p < 0.05). The microsurgeons with microsurgical fellowships preferred to use free flaps (32.9% versus 17.5%, multivariant p = 0.021). There was no difference for the seniority and specialty of the microsurgeons. CONCLUSIONS: The online questionnaire is valuable and feasible for obtaining experts' opinions. This study provides a current global overview of surgical preferences for this common complicated clinical scenario.

Surgical anatomy of the vascularized submental lymph node flap: Anatomic study of correlation of submental artery perforators and quantity of submental lymph node.

BACKGROUND: Harvesting the submental flap for vascularized lymph node transfer (VLNT) presents a challenging procedure because of, the topographic variation of the submental artery (SA) and the marginal mandible nerve (MMN) and the limited pedicle length for a free tissue transfer. The aim of this study was to evaluate surgical anatomical landmarks and variations of the submental lymph node flap (SLNF). METHODS AND MATERIALS: The authors examined the characteristics and landmarks of 18 SLNF in nine fresh cadavers. The diameter, length, and caliber of the SA and its relation to bony anatomic landmarks were measured. In addition, the number of lymph nodes (LNN) was evaluated through dissection and ultrasound. RESULTS: Within the designated SLNF (10 × 5 cm2 ), the number of LNN was on average 3 ± 0.6, with an average size of 4.5 ± 1.8 mm × 2.9 ± 1.2 mm. Projection of the LNN on the mandible, measured from the gnathion (GT, median-sagittal-plane) toward the gonion (GN, mandibular angle), was at 63.4 ± 5.8 mm (e.g., 65%) of the mandible for the first lymph node (LN), and for the following LNN was at 50.4 ± 7.7 mm (e.g., 52%), 44.0 ± 8.6 mm (e.g., 45%), and 40.50 ± 2.1 mm (e.g., 42%). The MMN consistently crossed the mandible body and the facial artery (FA) from dorso-caudal to ventro-cranial at 72 ± 5.2 mm, e.g., 75% of the mandible's length. Here, the nerve always lay superficial to the FA and was on average 0.96 ± 0.14 mm in diameter. Submental artery was located on average at 64 mm (e.g., 66%) of the mandible, with an average diameter of 1.34 ± 0.2 mm. CONCLUSION: The submental lymph node flap has a constant vascular supply by the submental artery. Lymph node count is on average three. Lymph nodes are close to the submental artery and its perforators. Marginal mandibular nerve lies superficial to the facial artery and crosses the artery at 75% of the mandible body length (gnathion to gonion = 100%). J. Surg. Oncol. 2017;115:54-59. © 2016 Wiley Periodicals, Inc.

The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study.

BACKGROUND: One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap. MATERIALS AND METHODS: In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system. RESULTS: On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle. CONCLUSIONS: The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.

The surgical anatomy of the supraclavicular lymph node flap: A basis for the free vascularized lymph node transfer.

BACKGROUND: Vascularized lymph node transfer is an effective surgical method in reducing lymphedema. This study provides the first detailed description of the surgical anatomy of the supraclavicular lymph node flap in regard to pedicle length, pedicle diameter, and the number of lymph nodes and their exact location inside the flap. METHODS: Bilateral supraclavicular dissections of nine fresh cadavers (five female) were performed. Before the dissection, the exact number of lymph nodes was determined sonographically by an experienced radiologist, and their distance from the jugular notch was measured. After anatomic dissection, the vascular pedicle's diameter and length were measured. RESULTS: The mean number of lymph nodes was 1.5 ± 1.85 on the right side and 3 ± 2.26 on the left. Their mean distance from the jugular notch was 8.29 ± 2.15 cm on the right and 6.10 ± 1.21 cm on the left. The pedicle's length was 4.72 ± 1.03 cm on the right and 4.86 ± 0.99 cm on the left, and its diameter 2.03 ± 0.83 on the right and 1.80 ± 0.77 on the left. CONCLUSION: The pedicle length and diameter of the supraclavicular lymph node flap are suitable for a microvascular tissue transfer. J. Surg. Oncol. 2017;115:60-62. © 2016 Wiley Periodicals, Inc.