Do the Histological Differences of Soft Tissue Sarcomas Affect the Rate of Skin Defect Reconstruction?

BACKGROUND: In soft tissue sarcoma (STS) resection, flap reconstruction and/or skin grafting is frequently required. However, it is not clear whether the histological difference affects the rate of reconstruction. The present study aimed to investigate it. METHODS: This study compared in 5 classifications (105 adipocytic tumors, 102 fibroblastic tumors, 39 muscle tumors, 31 peripheral nerve sheath tumors, and 178 tumors of uncertain differentiation). In addition, the reconstruction rates of detailed tumor sites were compared. The median and case number (percentage) were calculated. RESULTS: Tumor size (adipocytic 112 mm vs fibroblastic 79 mm, muscle 72 mm, nerve 90 mm, uncertain 74 mm, P < 0.0001 in all comparisons), histological low-grade rates (adipocytic 43.8% vs uncertain 3.9%, P < 0.0001; fibroblastic 46.1% vs muscle 15.4%, P = 0.003; fibroblastic vs uncertain, P < 0.0001; nerve 19.4% vs uncertain, P = 0.003) and reconstruction rates (adipocytic 5.7% vs fibroblastic 42.2%, muscle 33.3%, nerve 32.3%, uncertain 25.8%, P < 0.0001 in all comparisons) were significantly different. In the region of lower extremity, the regions of thigh [adipocytic 1/62 (1.6%) vs fibroblastic 7/32 (21.9%), P = 0.002], and lower leg [adipocytic 1/16 (6.3%) vs fibroblastic 11/19 (57.9%), P = 0.002] were significantly different. CONCLUSIONS: In adipocytic tumors, the tumor size was significantly large; however, the skin defect reconstruction rate was significantly lower than that of the other STS. Histologically, the reconstruction rate of STS derived from superficial tissue increases, whereas the reconstruction rate derived from deep tissue such as adipocytic tumor decreases.

Differences in Transient Fluid Retention and Lymphedema With Breast Cancer Treatment for Lymphatic Microsurgery.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a common complication. Repeated taxane-based chemotherapy has been shown to induce endothelial inflammation, leading to fluid retention. Patients with transient fluid retention only have upper limb edema without lymphatic dysfunction. Therefore, indocyanine green lymphography revealed linear findings, and lymphatic microsurgery is not required. This study aimed to investigate the difference between BCRL and fluid retention and present the indication for lymphatic microsurgery for these patients. METHODS: The study population was divided into BCRL and fluid retention groups. Age, body mass index, laterality, surgery type (lymph node, breast, or no surgery), disease stage, regional lymph node irradiation, hormone therapy, chemotherapy type (taxane- or non-taxane-based group), and treatment with trastuzumab were compared. RESULTS: The BCRL and fluid retention groups consisted of 168 and 73 patients, respectively. The BCRL group had significantly higher rates of axillary lymph node dissection (96.4%) and lymph node irradiation (51.8%) than the fluid retention group (53.4% and 24.7%, respectively; P < 0.001 for both). The fluid retention group had a significantly higher rate of taxane-based chemotherapy (100%) than the BCRL group (92.9%; P = 0.02). No significant differences in other characteristics, including treatments with hormone and trastuzumab, were observed. CONCLUSIONS: Lymphatic microsurgery should be performed after confirming the diagnosis by indocyanine green lymphography, particularly for patients with fluid retention induced by taxane-based chemotherapy. Because the generalized swelling induced by taxane-based chemotherapy is resolved 6 months after chemotherapy, we should wait at least 6 months to perform lymphatic microsurgery.

Relationship Between the Circumference Difference and Findings of Indocyanine Green Lymphography in Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a common complication. Indocyanine green (ICG) lymphography has been performed to assess lymphatic functionality. We found that some BCRL patients had a difference in circumference in partial regions only. The purpose of this study was to evaluate the patients with BCRL about the correlation between the difference in circumference and the findings of ICG lymphography. METHODS: One hundred fifty-five patients with unilateral BCRL were enrolled in this study. We evaluated the differences in circumference taken at 4 parts on the upper limb (at around the wrist, forearm, elbow, and brachium). The difference in circumference was evaluated between the affected part (Caf) and the unaffected part (Cun). We calculated the circumference difference rate (CDR) as follows: CDR = 100 (Caf - Cun)/Caf. First, we classified each part of all BCRL patients (620 parts) based on the findings of ICG lymphography (linear, collateral, dermal back flow [DBF], and no enhancement) and evaluated the correlation. Second, in the patients with partial volume change, we compared the mean CDR in each part. RESULTS: One hundred six parts were of a linear pattern, 31 parts were collateral, 350 parts were DBF, and 133 parts had no enhancement. The mean CDR of each finding was 3.3% in linear, 4.0% in collateral, 9.6% in DBF, and 9.4% in no enhancement. There was no significant difference between linear and collateral (P = 0.62), DBF, and no enhancement (P = 0.89) patterns. However, there was a significant difference between linear or collateral and DBF or no enhancement (all P < 0.001). In the 22 patients with distal DBF and proximal linear, the CDR was significantly higher in the forearm compared with the brachium (6.4% and 3.0%; P = 0.003). In the 26 patients with distal linear and proximal DBF, the CDR was significantly higher in the brachium compared with the forearm (4.3% and 7.7%; P = 0.005). CONCLUSIONS: There was a significant correlation between the difference in circumference and the severity of ICG findings.

Intraflap Vascular Catheterization Method for Monitoring, Prevention, and Intervention of Thrombogenesis in Free-Flap Surgery.

BACKGROUND: Thrombosis at the anastomotic site is a significant problem in free tissue transfer with microvascular anastomosis. We report a newly developed intraflap vascular catheterization (IFVC) technique for monitoring hemodynamics, prevention of thrombogenesis, and transcatheter intervention of free-flap thrombosis. METHODS: We performed a hospital-based, prospective study. Ninety-three patients underwent free tissue transfer by a single surgeon in a single hospital. In the IFVC group (n = 40), catheters were inserted into the arterial and venous branches of the flap main pedicle vessels near the anastomoses. The catheters were connected to the pressure monitor. A bolus injection of urokinase was administered every hour to the artery, and a continuous infusion of saline was initiated to the vein. The bolus injection of urokinase solution reached the arterial anastomosis by the retrograde flow. During the postoperative period, rapid injection of urokinase or saline was performed according to the pressure monitor. Intraflap vascular catheterization monitoring was performed postoperatively for 72 hours. RESULTS: The overall flap survival rate in the IFVC group was 100% (40 of 40), whereas the overall flap survival rate in the non-IFVC group was 96% (51 of 53). In a subgroup analysis of lower extremity reconstruction, the flap survival rate was 100% (22 of 22) with no cases of reanastomosis requiring a return to the operation room in the IFVC group. By contrast, the flap survival rate was 92% (22 of 24), with 6 cases of reanastomosis requiring a return to the operation room in the non-IFVC group (P = 0.04). CONCLUSIONS: The IFVC method enables monitoring, prevention, and intervention of thrombi at anastomotic sites of the free flap. Intraflap vascular catheterization may increase free tissue transfer success rate, especially in high-risk cases, such as free-flap reconstruction after the lower extremity trauma or venous leg ulcer.

The correlation of flap blood glucose with fat necrosis of free abdominal flap for unilateral breast reconstruction.

BACKGROUND: Flap blood glucose (FBG) measurement is proposed as a monitoring technique. A cause of long-lasting fever could be derived from fat necrosis. If the findings of low FBG correlated with fat necrosis, it could predict the poor cosmetic result and a source of fever. However, this correlation remained unsolved. The purpose of this study was to clarify this correlation in breast reconstruction. METHODS: In the 180 unilateral breast cancer patients (mean age = 49.8 years) performed free abdominal flap, we retrospectively compared the group where fat necrosis occurred with the group where it did not occur (45 patients with fat necrosis vs. 135 patients without). We compared the average of FBG in each postoperative day. RESULTS: The average FBG was significantly lower in patients with fat necrosis in the second postoperative day (115.3 ± 27.3 vs. 126.3 ± 13.7 mg/dl, p = .026) and the third postoperative day (111.1 ± 22.1 vs. 118.8 ± 13.8 mg/dl, p = .036). Mean BMI and inserted total flap weight were significantly higher in patients with the fat necrosis group (24.8 vs. 22.9 kg/m2 , p = .005) (617 vs. 478 g, p = .006). The multivariate analysis revealed early FBG (OR = 0.96, p = .0002) and laterality (right side) (OR = 0.46, p = .043) were independently significant predictors. There were no significant between-group differences regarding other factors (age, systemic blood glucose, comorbidities and operative details). CONCLUSIONS: The possibility of fat necrosis was high for patients with low FBG in the early postoperative day.

Epigenetic modifications underlie the differential adipogenic potential of preadipocytes derived from human subcutaneous fat tissue.

Ceiling culture-derived preadipocytes (ccdPAs) and adipose-derived stem cells (ASCs) can be harvested from human subcutaneous fat tissue using the specific gravity method. Both cell types possess a similar spindle shape without lipid droplets. We previously reported that ccdPAs have a higher adipogenic potential than ASCs, even after a 7-wk culture. We performed a genome-wide epigenetic analysis to examine the mechanisms contributing to the adipogenic potential differences between ccdPAs and ASCs. Methylation analysis of cytosines followed by guanine (CpG) using a 450-K BeadChip was performed on human ccdPAs and ASCs isolated from three metabolically healthy females. Chromatin immunoprecipitation sequencing was performed to evaluate trimethylation at lysine 4 of histone 3 (H3K4me3). Unsupervised machine learning using t-distributed stochastic neighbor embedding to interpret 450,000-dimensional methylation assay data showed that the cells were divided into ASC and ccdPA groups. In Kyoto Encyclopedia of Genes and Genomes pathway analysis of 1,543 genes with differential promoter CpG methylation, the peroxisome proliferator-activated receptor (PPAR) and adipocytokine signaling pathways ranked in the top 10 pathways. In the PPARγ gene, H3K4me3 peak levels were higher in ccdPAs than in ASCs, whereas promoter CpG methylation levels were significantly lower in ccdPAs than in ASCs. Similar differences in promoter CpG methylation were also seen in the fatty acid-binding protein 4 and leptin genes. In conclusion, we analyzed the epigenetic status of adipogenesis-related genes as a potential mechanism underlying the differences in adipogenic differentiation capability between ASCs and ccdPAs.

The utility of free abdominal flap without Zone 4 procedure for unilateral breast reconstruction.

BACKGROUND: The perfusion concept of free abdominal flap for breast reconstruction shares the common perception. We believed that free abdominal flap without Zone 4 could be performed. The purpose of this study is to introduce the "without Zone 4 procedure" and compare with the conventional technique (without 4 vs. conventional groups). METHODS: The "without 4 group" included 61 patients, while the conventional group 55 patients. The inclusion criterion for the "without Zone 4 procedure" was defined as the thickest part of flap was more than half of the contralateral breast projection. The centerline of the skin island was adjusted to the position with the most medial side of the perforator. We compared basic characteristics (age, BMI, operation time, blood loss, contralateral breast size, smoking status, and history of laparotomy), the flaps' horizontal and vertical widths, thickness of the thickest part of the flap, elevated flap weight, and operative procedure. RESULTS: The mean length of the flaps' horizontal width was significantly shorter (19.2 cm vs. 26.3 cm; p < .001) and the mean flap thickness was significantly greater in the without 4 group. The mean contralateral breast height and projection length were significantly longer in the conventional group. No significant differences were found with respect to the other characteristics. CONCLUSIONS: Patients with a lower breast projection compared with the abdominal fat thickness could undergo reconstruction with a shorter flap horizontal width. Because of the esthetic outcome of the donor site, this procedure is more appropriate for low-BMI patients.

Correlation of the changes in physical activity and clinical results following lymphatic microsurgery.

BACKGROUND: The physical activity (PA) of patients may change after microsurgical treatment for lower extremity lymphedema (LEL). We investigated whether PA changes perioperatively and whether it influences the treatment result. PATIENTS AND METHODS: Sixty patients with unilateral LEL (56 secondary and 4 primary) underwent lymphatic microsurgeries. Patients were divided into two groups based on improvement in International Physical Activity Questionnaire Short Form (IPAQ-SF) categories; the outcomes were compared. RESULTS: Fifty-three patients in whom linear pattern could be partially observed in indocyanine green lymphography or lymphoscintigraphy underwent lymphaticovenular anastomosis (LVA); seven patients in whom no linear pattern was observed underwent simultaneous LVA and vascularized lymph node transfer. No surgical complication was observed. The median IPAQ-SF score significantly improved from 990 (interquartile range: 231-2,376) to 1,386 (interquartile range: 940.5-4,158; p < .0001). The IPAQ-SF category improved in 22 patients (33.7%), who were categorized into the IPAQ-improved group. Improvement in excess limb volume was significantly larger in the IPAQ-improved group than that in the unimproved group (8.0 ± 4.2 vs. 3.5 ± 2.4%; p < .0001). CONCLUSION: The PA of patients may change after surgical treatment for unilateral LEL. Perioperative improvement in PA significantly correlated with the perioperative change in the excess limb volume. The change in PA is an important factor that might affect the outcome of surgical treatment for LEL. In evaluating the results of microsurgery for lymphedema, it may be necessary to consider changes in PA to avoid bias.

Anti-HER2 antibody therapy using gene-transduced adipocytes for HER2-positive breast cancer.

PURPOSE: Although recent advances in molecular target therapy have improved the survival of breast cancer patients, high cost and frequent hospital visits result in both societal and individual burden. To reduce these problems, it has been proposed to produce antibodies in vivo. Here, we constructed gene-transduced human ceiling culture-derived proliferative adipocytes secreting anti-HER2 antibody (HER2-ccdPAs) and evaluated their ability to secrete antibody and mediate an anti-tumor effect. METHODS: Plasmid lentivirus was used as a recipient for anti-HER2 antibody cDNA and transduced into human proliferative adipocyte. Secretory antibody expression was evaluated by ELISA and western blot. Specific binding of secretory antibody to HER2 was examined by immunofluorescence analysis. Direct and indirect anti-tumor effects of supernatants from HER2-ccdPAs were evaluated using BT474 (HER2+) and MDA-MB-231 (HER2-) breast cancer cell lines. Additionally, whether adipocyte differentiation affects antibody secretion was investigated using supernatant collected from different cell maturation states. RESULTS: Anti-HER2 antibody was identified in the supernatant from HER2-ccdPAs and its production increased with the differentiation into mature adipocyte. Antibodies in supernatants from HER2-ccdPAs bound to HER2-positive breast cancer cells similar to trastuzumab. Supernatant from HER2-ccdPAs inhibited the proliferation of BT474 but not MDA-MB-231 cells, and downregulated AKT phosphorylation in BT474 cells compared with controls. Supernatants from HER2-ccdPAs also had an indirect anti-tumor effect on BT474 cells through ADCC. Additionally, Single inoculation of HER2-ccdPAs showed an anti-tumor effect in BT474 xenograft model. CONCLUSIONS: HER2-ccdPAs might be useful for cell-based gene therapy. This system could be a platform for various antibody therapies.

Small intestinal bacterial overgrowth as a cause of protracted wound healing and vitamin D deficiency in a spinal cord injured patient with a sacral pressure sore: a case report.

BACKGROUND: Pressure sores are sometimes refractory to treatment, often due to malnutrition. Small intestinal bacterial overgrowth (SIBO) obstructs absorption in the digestive tract and causes malnutrition. However, little is known about the association between pressure sore wound healing and SIBO. Here, we report a case of a patient with a refractory sacral pressure sore and SIBO. CASE PRESENTATION: A 66-year-old woman who was spinal cord injured 14 years before visiting our hospital presented with the chief complaint of a sacral pressure sore, 10.0 × 6.5 cm in size, which was refractory to treatment. Physical examination showed abdominal distension and emaciation, with a body mass index of 15. Further examination revealed elevated serum alkaline phosphatase (1260 U/L), bilateral tibial fracture, multiple rib fracture, and osteoporosis. We diagnosed the patient with osteomalacia with vitamin D deficiency. Despite oral supplementation, serum levels of calcium, phosphorous, and vitamin D remained low. Also, despite concentrative wound therapy for the sacral pressure sore by plastic surgeons, no wound healing was achieved. Due to a suspicion of disturbances in nutrient absorption, we performed bacterial examination of collected gastric and duodenal fluid, which showed high numbers of bacteria in gastric content (104 E. coli, 105 Streptococcus species, and 105 Neisseria species) and duodenal content (106 E. coli, 104 Candida glabrata). Therefore, we diagnosed the patient with SIBO and started selective decontamination of the digestive tract using polymyxin B sulfate and amphotericin B. After starting treatment for SIBO, the sacral pressure sore began to heal and was nearly healed after 285 days. The patient's serum levels of calcium, phosphorous, vitamin D, and other fat-soluble vitamins also gradually increased after starting treatment for SIBO. CONCLUSION: We report a case of a patient with a refractory sacral pressure sore that healed after starting treatment for SIBO. We conclude that SIBO may be an overlooked cause of malnutrition and poor wound healing in patients with chronic pressure sores.

Disseminated zoster in an adult patient with extensive burns: a case report.

BACKGROUND: Shingles (localized zoster) and disseminated zoster are caused by the reactivation of latent varicella zoster virus (VZV). Reactivation of VZV is related to impaired cell-mediated immunity. Extensive burns affecting a patient result in burn-related immunosuppression and cytokine storm. Despite immunosuppression in burn patients, the reactivation of VZV is extremely rare, whereas eczema herpeticum, caused by reactivation of latent herpes simplex virus (HSV), is common. We have found only 1 published case of VZV reactivation during burn treatment in the literature. CASE PRESENTATION: A 51-year-old man was burned in a fire, which affected 60% of his total body surface area (TBSA), and also received inhalation injury (day 0). Despite fluid resuscitation, he showed persistent renal failure. Continuous hemodialysis and filtration (CHDF) combined with polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) therapy was used for cytokine modulation. Autologous and allogeneic skin grafting was performed. On day 15, multiple-drug-resistant Pseudomonas aeruginosa (MDRP) was detected from a blood specimen, and the patient developed multiple organ failure (MOF). On day 31, compact aggregations of small vesicles appeared on the intact skin of his left knee and left buttock. The vesicles were located within the 4th lumbar (L4) spinal dermatome. From day 32 to day 34, similar new vesicles arose on his intact skin and epithelializing skin-graft donor sites. We diagnosed disseminated zoster, based on the patient's age, the characteristic occurrence of the initial vesicles within a limited area of intact skin in the left L4 dermatome, and a positive Tzank smear. Serologic testing on day 36 showed a high level of anti-VZV immunoglobulin (Ig)G with low levels of anti-VZV IgM, anti-HSV IgG, and anti-HSV IgM. The patient was isolated in a negative-pressure room to avoid air-borne spread of VZV. On day 52, the patient died. CONCLUSIONS: To the best of our knowledge, our patient is the second case of reactivation of VZV during burn treatment. It is unclear why reactivation of VZV is rare in patients with burn-related immunosuppression, whereas HSV reactivation is common. Cytokine modulation throughout the treatment period using CHDF combined with PMX-DHP might have been related to the rare reactivation of VZV in our patient. Our case provides an additional information on the relationship between the immune status of a patient with extensive burns and reactivation of latent VZV or HSV.

The beneficial effect of traditional Japanese herbal (Kampo) medicine, Hochu-ekki-to (Bu-Zhong-Yi-Qi-Tang), for patients with chronic wounds refractory to conventional therapies: A prospective, randomized trial.

Hochu-ekki-to (HET) is a traditional Japanese herbal (Kampo) medicine for the treatment of severe weakness, loss of appetite, and indigestion in elderly patients and for the prevention of opportunistic infections. The impact of HET on patients with chronic wounds refractory to conventional therapies was investigated in a prospective, randomized trial, including 18 patients divided into medication (7.5 g oral HET per day, n = 9) and control (n = 9) groups. Wound healing during the 12-week study period was scored based on depth, exudate, size, inflammation/infection, granulation tissue, necrotic tissue, and pocket size. At 12 weeks, wound healing progressed in all nine patients in the medication group, whereas wound healing progressed in only three patients in the control group (significant difference, p < 0.01; relative risk: 3.00). In the medication group, the total score decreased significantly at 8 weeks and later. To the best of our knowledge, this study was the first to show that HET promoted the healing of chronic wounds resistant to conventional treatments. HET may be a choice as an adjunctive therapy for chronic wounds, particularly for patients with malnutrition. This trial was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN000031620).

A method using the cephalic vein for superdrainage in breast reconstruction.

BACKGROUND: In breast reconstruction, a superdrainage procedure using the superficial inferior epigastric vein has been described. The purpose of this study was to investigate whether the utility of cephalic vein (CV) was equivalent to that of serratus anterior muscle branch of the thoracodorsal vein (SA) and lateral thoracic vein (LTV) for recipient vein. METHODS: Eighty-eight patients were enrolled in this study. The superdrainage was not performed if the internal mammary vein diameter was greater than, or equal to, that of the deep inferior epigastric vein diameter. In superdrainage cases, the SA or LTV was used as the recipient vein firstly, and the CV was used when both of them were unsuitable. RESULTS: The superdrainage was performed in 45 (51.1%) patients. No significant differences were observed between with and without superdrainage. In superdrainage group, the CV was used in 7 (15.5%) patients. In two groups (CV vs. LTV and SA), because we added to perform superdrainage to the CV at the time of re-exploration and tried to use the SA or the LTV firstly, the re-exploration rate (28.6 vs. 0%) and operating time (652.1 vs. 591.1 min) of CV group were significantly high (p = .023 and .028). No complications were observed, due to CV harvesting. Other characteristics showed no significant differences. CONCLUSIONS: At the point of superdrainage, the CV was equivalent to the SA and LTV. Using of the CV would only be essential in rare cases; nonetheless, the possibility of its use should be considered.

A comparison study of deep muscle sparing transverse rectus abdominis musculocutaneous flap for breast reconstruction.

BACKGROUND: Breast reconstruction by deep inferior epigastric perforator flap (DIEP) involves only little rectus abdominis muscle sacrifice. However, the operative procedure may get complicated. We propose here a novel method involving two adjacent perforators and requiring the addition of only the superficial muscle to the flap. This novel technique, termed "deep muscle sparing transverse rectus abdominis musculocutaneous flap (DMS-TRAM)," was compared to DIEP and MS-TRAM groups. METHODS: The subjects were 70 patients. The indication of DMS-TRAM was the distance between two perforators penetrating the deep fascia was <3 cm, and the two perforators ran through the superficial layer of the muscle until they became confluent. All patients were evaluated by contrasting computed tomography. The data of age, body mass index, flap volume, operative time, blood loss, laterality, immediate reconstruction, prior radiation, smoking, re-exploration, total flap necrosis, partial fat necrosis, and abdominal bulging were compared. Ultimately, DMS-TRAM was applied in 20 subjects (28.6%), DIEP in 31 (44.3%), and MS-TRAM in 19 (27.1%). RESULTS: The volume of blood loss in the DIEP group was significantly higher than that in the DMS-TRAM group (328 ± 182 vs 454 ± 217 mL, p = 0.02), the other factors did not significantly influence. The rate of fat necrosis in DIEP tended to be high (10.0% vs 22.6%, p = 0.22). CONCLUSIONS: Because DMS-TRAM could preserve the deep muscle and penetrating side of intercostal nerve, it could be performed less sacrifice and there were few bleeding and partial necrosis at the same level as MS-TRAM. DMS-TRAM was effective in the applied cases.

Intraoperative Detection of Efferent Lymphatic Vessels Emerging from Lymph Node during Lymphatic Microsurgery.

BACKGROUND: Although the usefulness of efferent lymphaticovenular anastomosis (ELVA) in lymphatic microsurgery has been reported, the optimal method to distinguish efferent from afferent lymphatics is not yet established. We propose a novel technique to detect efferent lymphatics appropriate for anastomosis. METHODS: In total, 62 groin lymph nodes (LNs) of 46 limbs were divided into four groups based on the findings of indocyanine green lymphography: n = 15 in normal, 15 in dermal backflow stage 0, 18 in stage I, and 14 in stage II groups. The target LN and afferent lymphatic connecting it were preoperatively detected using ultrasonography. Intraoperatively, 0.05 mL patent blue dye was slowly manually injected from the afferent lymphatic; the lymphatic(s) subsequently stained was diagnosed as the efferent lymphatic(s) emerging from the node. The success rates of efferent lymphatic detection, sizes of LN, and diameter of efferent lymphatics were compared among the groups. RESULTS: Both LN size and diameter of efferent lymphatic were significantly larger in the stage 0 and I groups than the other groups (p < 0.01). Efferent lymphatic could be stained in 13, 13, 18, and 9 LNs in the normal and stage 0, I, and II groups, respectively. A significant difference was observed between the stage I and II groups regarding the success rate of efferent lymphatic detection (p = 0.04). CONCLUSION: Efferent lymphatics could be detected using patent blue dye in 85.5% of the cases. The patients in early-stage lymphostasis might be the most appropriate candidates for ELVA.

Use of Vascularized Sural Nerve Grafts for Sciatic Nerve Reconstruction After Malignant Bone and Soft Tissue Tumor Resection in the Lower Legs.

BACKGROUND: Vascularized nerve grafting is normally associated with a good outcome, but can be difficult to use for nerve reconstruction in patients with long defects of the sciatic nerve given the graft thickness. We report 3 cases of large defect sciatic nerve reconstruction using the bilateral sural nerves of the lower legs harvested together with the fascia and lesser saphenous vein to form a vascularized flap. METHODS: The subjects were 3 patients who required the reconstruction of a 10-cm or longer segment of the sciatic nerve. Priority was given to restoring sensation in the plantar region such that reconstruction of the sensory nerves corresponding to the tibial region. RESULTS: Two patients were followed up for long term. There was some persistent perceptual deficit in the foot, minimal protective sensation had been achieved. CONCLUSIONS: We were able to selectively reconstruct the sensory nerves to achieve sensation in the soles of the feet by using sural nerve grafts from both legs. As the prognosis for the underlying condition in cases necessitating this procedure is often poor, the costs and benefits of reconstruction should always be weighed carefully for each individual patient.

Improvement of the efficacy of vascularized lymph node transfer for lower-extremity lymphedema via a prefabricated lympho-venous shunt through lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated vascularized lymph node.

BACKGROUND: Following vascularized lymph node (VLN) transfer (VLNT), the VLN may be at a risk for sclerosis because of efferent lymphatic vessel obstruction. We developed a new technique to prevent VLN sclerosis via a prefabricated lympho-venous (LV) shunt. This study compared the treatment outcomes of single VLNT with prefabricated LV shunt, conventional multiple VLNTs, and conventional single VLNT. METHODS: Overall, 47 limbs of 45 patients that underwent VLNT for lower-extremity lymphedema (LEL) in late clinical stage II/III were divided into 3 groups: conventional single VLNT group (control; 21 limbs where 4 had primary LEL), multiple VLNTs group (13 limbs where 3 had primary LEL), and prefabricated LV shunt group (13 limbs where 4 had primary LEL). In the prefabricated LV shunt group, lymphaticovenular anastomosis between the efferent lymphatic vessel and small vein in the elevated VLN were performed simultaneously with VLNT. RESULTS: Although venous thrombosis at the anastomosis site was observed in 1 case, it was salvaged by re-anastomosis, and all VLNs survived. No other complications were observed. The LEL index significantly improved in the prefabricated LV shunt group compared with that in the control group (28.0 ± 1.7 vs 20.9 ± 1.5, P = 0.02). In the prefabricated LV shunt group, all VLNs survived functionally, and the average size of the transferred lymph nodes was significantly larger than that of the control group (5.7 ± 0.1 vs 4.3 ± 0.2 mm, P < 0.01). CONCLUSIONS: Prefabricated LV shunt may improve the efficacy of VLNT.

Intraoperative objective evaluation of venous congestion in deep epigastric artery perforator flap breast reconstruction: A pilot study.

BACKGROUND: In a deep epigastric artery perforator (DIEP) flap breast reconstruction, the necessity of additional anastomosis of the superficial inferior epigastric vein (SIEV) should be determined intraoperatively. The purpose of this pilot study is to propose a method to detect venous congestion intraoperatively using the blood glucose measurement index (BGMI). METHODS: In 70 DIEP flaps of 67 patients for breast reconstruction, the ratio of blood glucose content in the flap to systemic blood glucose (BGMI) was measured immediately after wound closure. Eight flaps in which BGMI was less than 0.8 were categorized into the low BGMI group, and additional venous anastomosis using SIEV was conducted. The other 62 flaps were categorized into the normal BGMI group. Perioperative objective color difference of the flap calculated using the L*a*b* color coordinate scale was recorded simultaneously. Correlation between BGMI and color difference was analyzed. RESULTS: In all flaps in the low BGMI group, SIEV diameter was increased; after additional anastomosis, the BGMI significantly improved (from 0.71 ± 0.05 to 0.94 ± 0.05, P < .01). There was a significant correlation between BGMI and color difference (P = .04). The determination coefficient was 0.265. When a BGMI of less than 0.8 was assumed to be a true positive, the area under the curve of color difference in the receiver operating characteristic curve was 0.82. CONCLUSION: BGMI immediately after wound closure may be useful to detect initial signs of venous congestion. Intraoperative objective color difference also reflects venous congestion; however, it is not highly accurate.

Noninvasive screening test for detecting early stage lymphedema using follow-up computed tomography imaging after cancer treatment and results of treatment with lymphaticovenular anastomosis.

BACKGROUND: Although early detection is valuable for secondary lymphedema treatment, existing screening tests are not popular. This study aimed to propose a novel method of screening lymphedema patients based on the thickness of the subcutaneous fat measured with perioperative computed tomography (CT) and present the results from evaluation of patients who underwent those examinations was performed. METHOD: The medical records of 96 gynecological cancer patients and 189 breast cancer patients, whose lymphatic function was assessed with indocyanine green lymphography, were reviewed. In gynecological cancer patients, the perioperative temporal subcutaneous fat thickness index (T-SFTI) was calculated from presurgical and follow-up CT data, and in breast cancer patients, the postoperative crosswise subcutaneous fat thickness index (C-SFTI) was calculated. In lower extremity lymphedema patients, the effect of lymphaticovenular anastomosis (LVA) was also evaluated using T-SFTI. RESULTS: Perioperative T-SFTI was assessed in 180 lower extremities, and it was significantly higher in 46 lymphatic dysfunction limbs (1.21 ± 0.08) than in 134 normal lymphatic function limbs (1.03 ± 0.08), (P < .01). Postoperative C-SFTI was assessed in 53 upper extremity, and it was significantly higher in 11 lymphatic dysfunction limbs (1.31 ± 0.21) than in 42 normal lymphatic function limbs (1.01 ± 0.06), (P < .01). In lower extremity lymphedema patients, T-SFTI improved significantly after planned conservative treatments and LVA (P = .04). CONCLUSION: Assessment of subcutaneous fat thickness using CT is useful for screening early stage lymphedema. If the efficacy of this method is validated, patients worldwide may be assessed using the same criterion.

Clinical Experience of Treatment of Facial Malformations in Oto-Palato-Digital Syndrome: A Familial Patient.

Oto-palato-digital syndrome type 1 (OPD1) is an X-linked recessive disorder comprising characteristic facial appearances and skeletal alterations. The authors report OPD1 in a mother and her 2 sons who had multiple common congenital anomalies. Both of the brothers were born with mild hearing impairment, frontal bossing with prominent supraorbital ridges, downslanting palpebral fissures, dental malocclusion, and palatal clefts. They underwent a series of aesthetic surgeries for their facial malformations with good cosmetic results. The mother had a milder phenotype with less prominent craniofacial defects that did not require surgical correction. The older brother required a 2-jaw surgery whereas the younger brother required a surgically assisted rapid palatal expansion. In the second series of operations, both brothers underwent scraping of their prominent supraorbital ridge. They have been free of complications throughout their 16-year follow-up. The authors also screened the family for possible genetic etiologies and identified mutations in the causative gene of OPD1 on Xq28 in all 3 patients. In conclusion, the authors have identified 3 patients with OPD1, performed surgical treatments on the affected brothers and have obtained good reconstructive results. There are no reports involving OPD1 patients who have received good surgical treatment. With careful examination and identification of patients with characteristic facies and skeletal abnormalities, it is our opinion that the authors can help more patients with this disease through surgical management.