A. Frick

Liposuction technique and lymphatic lesions in lower legs: anatomic study to reduce risks.

Liposuction is a standard procedure in plastic surgery. Especially, lipectomy with suction of the lower extremities has been of greater interest in recent years. Until now, however, there was no definite information about the integrity of epifascial lymph collectors during this procedure. To study the effect of liposuction devices on lymph vessel injury, postmortem lymphatic preparations were done in five human cadavers (10 lower extremities). Conventional liposuction with a blunt 4-mm cannula and a dry technique was used. Adiposuction was performed either in parallel to the extremity axis and, therefore, in parallel to the superfascial lymph vessels or transversally in an 80- to 90-degree angle to the extremity. Careful surgical preparation of the regions followed. A specific macroscopic lymph vessel injury score was applied to differentiate 3 degrees of lymph vessel lesions according to the extravasation of patent blue. In all lower extremities, postmortem lymph flow occurred as indicated by patent blue staining of the lymph vessels. Lymph vessel injury was more severe in areas where liposuction was performed transversally, vertical to the extremitys axis, than in those after a longitudinal procedure. The difference was statistically significant (p < 0.01). The volumes of adipoaspirate and of the compared regions were comparable between both groups, verified by circumference measurements. Longitudinal liposuction of the lower extremities is unlikely to cause major lesions of epifascial lymph vessels and, therefore, should be preferred in comparison to liposuction vertical to the extremity.

Tumescent and dry liposuction of lower extremities: differences in lymph vessel injury.

Lipectomy is a standard procedure in plastic surgery. Until now, however, there was no definite information about the influence of different liposuction techniques (tumescent versus dry liposuction) on the integrity of lymph collectors during this procedure. To study the effect of these liposuction techniques on the incidence of lymph vessel injury, postmortem lymphatic preparations were done in nine human cadavers (18 lower extremities). Conventional liposuction with a blunt 4-mm cannula in the dry technique (n = 29 regions) was compared with the tumescent technique (n = 26). Liposuction was performed in parallel to the superficial lymph vessels (longitudinal suction) or transversally in an 80-degree to 90-degree angle to the extremity (vertical suction). Careful surgical preparation of different regions followed. A specific macroscopic lymph vessel injury score was applied to differentiate three degrees of lymph vessel lesions according to the extravasation of patent blue. In all lower extremities, postmortem lymph flow occurred as indicated by patent blue staining of the lymph vessels. Injection of fluid that is obligatory during tumescent suction did not result in grade 2 injury. On the contrary, tumescent suction overall produced significantly fewer lymph vessel lesions when compared with the dry technique (p < 0.05). Longitudinal liposuction produced significantly less injury when compared with vertical suction (p < 0.05). Tumescent suction and dry suction were equally effective in removing adipose aspirates, as verified by circumference measurements. In addition, tumescent liposuction is unlikely to cause major lesions of epifascial lymph vessels during suction procedures vertical to the extremity axis. Therefore, in this respect, this technique is superior to dry suction.

Microsurgical Lymphatic Vessel Transplantation

BACKGROUND Lymphedema often arises after a regional interruption during cancer treatment, for example after lymph node resection the axilla or the groin. Lymphatic vessels as vascular grafts may overcome these lymphatic gaps. METHOD Experiments in rats and dogs were performed for developing this method. Volume measurements, lymphoscintigraphies, proof of patency by MRI and radiology as well as quality of life studies were performed in patients. RESULTS Long-term follow-up studies revealed significantly reduced volumes, significant improvement of lymphatic outflow shown by lymphoscintigraphy, long-term patency of the grafts for more than 10 years, and improved quality of life after surgery compared with the situation with conservative treatment before surgery. CONCLUSION Vascular grafts using the patients own lymphatic vessels are able to successfully reconstruct a locally interrupted lymphatic pathway.

Endoscopic-assisted microsurgery: microsurgery in the new millennium? A comparative experimental study

Endoscopes are already present in almost all plastic surgery departments. The operating microscope is currently an essential piece of equipment for performing microsurgical anastomoses; however, microsurgery could be conducted using other equipment, including the endoscope. By performing 60 vessel and nerve repairs in rats under the operating microscope and the same number using the endoscope as a visual aid, we investigated the technical and clinical differences between the two instruments. We recorded significantly shorter operative, vascular preparation and anastomotic times in the endoscopically assisted group. Based on the data collected during this study, we conclude that microsurgery is possible with the aid of an endoscope. Using the endoscope may make prolonged microvascular procedures shorter and less physically demanding and may increase the comfort level of both the surgeon and the assistant.

Technique and proof of patency of microsurgical lympho-lymphonodular anastomoses: a study in the rat model.

Background: Lymphedemas due to local lymphatic blocks can be treated by microsurgical transplantation or transposition of lymphatic vessels. Here, the anastomoses are usually made end‐to‐end between lymphatics, but occasionally appropriate lymphatic recipient vessels are missing. In such cases, reconstructing lymph drainage by connection to a lymph node could be another technical option. The purpose of this study was to examine the patency rate of such lympho‐lymphonodular anastomoses in an experimental animal model. Methods: Male Sprague–Dawley rats were anesthetized, and the retroperitoneum was exposed. Patent blue dye was injected into the left foot to stain lymphatic structures. In group A (n = 8), the left lumbar trunk was cut centrally, the distal part was turned over to the right lumbar lymph node, and a microsurgical lympho‐lymphonodular anastomosis was performed. In group B (n = 8), the left lumbar trunk was cut. After 8 weeks, the lumbar region was surgically re‐explored, and the lymphatic drainage was examined by injection of Patent blue dye into the left lumbar lymph node. Results: In 8/8 animals of group A, patent transposed lymphatics were found. The patency of the anastomosis was proven directly by observation of blue dye transit and indirectly by observation of blue staining of the right lumbar lymph node. In 6/8 animals of group B, no lymphatic connection to the right lumbar lymphatic system was observed. Conclusions: This is the first report of the microsurgical technique and the proof of patency of lympho‐lymphonodular anastomoses. The novel animal model for testing the patency of transposed lymphatics is discussed.

Lymphedema of the upper limb: evaluation of the functional outcome by dynamic imaging of lymph kinetics after autologous lymph vessel transplantation.

Purpose The aim of this study was to evaluate by lymphoscintigraphy the functional outcome after autologous lymph vessel transplantation (Tx) of the upper limb. Methods One hundred seventy-seven patients (172 female, 5 male; median age, 56 years; range, 12-84 years) presenting with Tx situs in an upper limb were included. For correlation of scintigraphic data versus reduction of volume (RV) surplus measurements, we examined at 4 different time points as follows: preoperatively (T0), within 2 weeks after Tx (T1), 6 to 12 months after Tx (T2), and 32 to 38 months after Tx (T3). An additional long-term follow-up after at least 8 years (T4) was available in some cases. Results The maximum individual postoperative observation period was 19 years. In 169 of 177 cases, lymphedema had been caused by treatment of breast cancer (mastectomy, n = 103/169; breast preserving, n = 66/169) and/or radiation therapy (n = 130/177), but 2 patients presented with primary lymphedema. The remaining 6 cases of lymphatic disorders were caused by treatment of malignant melanoma, Hodgkin lymphoma, axillary Ewing sarcoma, non-Hodgkin lymphoma, hemangioma, or abscess removal. At T1, the mean RV of the affected limb was 73%, and the mean improvement of transport index (TI) was 28%. At T2, the RV was 64% and the TI was 23%, and at T3, the RV was 63% and the TI was 25%. Long-term follow-up after at least 8 years (T4: range, 9–19.2; mean, 14.1 years) was available in 19 of 177 patients, in whom persistent improvement in the scintigraphic data (25% decrease in TI) was confirmed by a mean clinical RV of 68%. The mean overall correlation was by a factor of 2.64. Conclusions Our findings in this large set of patients undergoing autologous lymph vessel Tx to an upper limb confirm that this microsurgical technique significantly and persistently improves lymph drainage in patients with lymphedema. The findings of lymphoscintigraphy correlated well with volume measurements at long-term follow-up.

Update on special surgical approaches in the therapy for lymphedemas

Despite recent medical progress primary and secondary lymphedemas still represent a therapeutic challenge and they often lead to a significant reduction in quality of life. Lymphedemas usually develop in the extremities, the male external genitals as well as the female breast as a consequence to the axial alignment of the lymphatic collectors. Early stages are characterized by an excess of lymph fluid increasing the volume of the affected part of the body whereas later stages represent an increasing amount of solid tissue. Thus therapeutic efforts can focus on the reduction of the surplus of liquid and/or solid components. Generally there are conservative and operative strategies. Conservative measures mainly focus on the improvement of fluid mobilization and drainage and comprise compression garments, manual lymphatic drainage, and apparative intermittent compression. Operative approaches comprise procedures for surgical tissue reduction (symptomatic/ablative approaches) and/or procedures with the intention of enhancing lymphatic transport (causal approaches). Surgical tissue reduction can be performed by open resection and/or liposuction. Traditional surgical causal techniques such as transposition of local flaps aim at leading lymph away from the congested region of the body. Modern microsurgical causal approaches contain methods of reconstruction of interrupted lymphatic pathways as well as techniques for the conduction of lymph into local veins. In this review we depict and discuss the features of the multiform spectrum of the surgical therapy of lymphedemas on the basis of literature as well as our own clinical and experimental experience.

Langzeitergebnisse nach Replantation von Extremitätenteilen

Zwischen Januar 1982 und Marz 1993 wurden 278 Teile von Extremitaten replantiert. Darunter waren 260 Fingerreplantationen, 16 Replantationen der oberen Extremitat und 2 Replantationen der unteren Extremitat. Zusatzlich wurde eine Penisreplantation durchgefuhrt. Fur die Langzeitnachuntersuchung wurden Patienten aus den Jahren 1982 bis 1987 ausgewertet; es handelte sich um 55 Manner und 7 Frauen. Es ergab sich eine Mindestnachbeobachtungszeit von 5 Jahren. Eine Klassifikation der Ergebnisse wurde in Anlehnung an Chen durchgefuhrt. Unter Einbeziehung aller Replantationen zeigten 43% der Patienten Grad 1, 36% Grad 2, 19% Grad 3. 1 Patient wies Grad 4 und damit ein funktionsloses replantiertes Extremitatenteil auf. 43% der Patienten arbeiten voll in ihrem alten Beruf, 22% befanden sich in Um- und Weiterbildung. 20% konnten keiner Arbeit mehr nachgehen.

The free groin flap in the rat: a model for improving microsurgical skills and for microvascular perfusion studies

Abstract The goal of this study was to evaluate the free groin flap in the rat transplanted to the neck as a tool for extending microsurgical skills and to assess its suitability as a model for microvascular perfusion studies following secondary venous ischaemia. An analysis of 60 consecutive groin flap transplantations was performed in male Sprague Dawley rats with special regard to anatomy and operation times (Part I, animals No. 1–60). Following flap transplantation, the animals No. 10–30 (n = 21) were used for the determination of the critical time period of a complete venous stasis of the free groin flap resulting in a total flap loss (Part II). The flaps of animals No. 31–41 (n = 11) were used for assessing the feasibility and reproducibility of intra-vital video microscopy (IVM) of the flaps (Part III). The mean total operation time decreased from 166 (± 26) minutes ins the first 10 animals to 126 (± 21) minutes and 130 (± 12) minutes in the latter two groups of 10 animals, respectively. After a critical period of 35 minutes of a complete artificial venous stasis a complete flap necrosis occurred. IVM detected a higher functional capillary density of the skin of the transplanted groin flaps in the animals in which the flaps were rinsed with 1 ml of Ringers lactated solution prior to I/R. In conclusion, this model is simple and reliable. The model may be a useful tool for evaluating and comparing the effects of various anticoagulants or vasomotor drugss on microvascular perfusion in critically compromised free flaps.

Mikrochirurgische autologe Lymphgefäß-Transplantation: Verursacht die Entnahme von Lymphgefäß-Transplantaten Lymphtransportstörungen an der Spenderextremität?

OBJECTIVE The aim of this study was to determine whether the extirpation of lymphatic vessels induces lymphatic transport disturbances in the donor limb of patients following the harvest of lymph vessel grafts. PATIENTS, MATERIAL AND METHODS A total of 19 consecutive patients (15 females, 4 males; mean age 51.5 years, range 21.8-72.3) were examined by lymphoscintigraphy before and after surgery. The patients had previously been diagnosed with upper or lower limb lymphoedema in accordance with the criteria of the International Society of Lymphology, and autologous lymph vessel transplantation had been intended for treatment. Since only patients with normal scintigraphic tests at the harvesting site were considered for treatment, all consecutive patients (n=19) had normal scintigraphic tests of the donor limb prior to surgery. In order to quantify the visual scintigraphic findings, a well established numeric transport index (TI) was used, which combined 5 visual parameters of transport kinetics. To that end, the following visually assessed criteria were evaluated: temporal and spatial kinetics, radiopharmaceutical distribution pattern, time to appearance of inguinal lymph nodes, qualitative visualisation of lymph nodes and lymph vessels. RESULTS All patients underwent a preoperative scintigraphic baseline study and a postoperative scintigraphic follow-up after autologous lymphatic vessel grafting. The mean time period from the baseline study to the date of microsurgical lymph vessel transplantation was 3.5 months (median 2.5 months). The scintigraphic follow-up was performed 48.6 months (median 57.8 months) following transplantation. In all patients the postoperative TI was very close to the TI calculated in the preoperative baseline scintigraphy, and all TIs were within the normal range (TI<10). The absolute value of deviation of pre- vs. post-operative transport indices was calculated to be 0.2 on average (maximum 0.4). CONCLUSIONS The results show that microsurgical transfer of lymph vessel grafts is possible without compromising lymphatic drainage of the donor limb if safety precautions are taken into account.