Dung H. Nguyen

A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle

OBJECTIVE Vascularized groin lymph node flaps have been successfully transferred to the wrist to treat postmastecomy upper limb lymphedema. This study investigated the anatomy, mechanism and outcome of a novel vascularized submental lymph node (VSLN) flap transfer for the treatment of lower limb lymphedema. METHODS Bilateral regional submental flaps were dissected from three fresh adult cadavers for histological study. A unilateral submental flap was dissected in another six fresh cadavers after latex injection. The VSLN flap was transferred to the ankles of seven lower extremities in six patients with chronic lower extremity lymphedema. The mean patient age was 61 ± 9.4 years. The average duration of lymphedema symptoms was 71 ± 42.2 months. RESULTS There was a mean of 3.3 ± 1.5 lymph nodes around the submental artery typically at the junction with the facial artery, on the six cadaveric histological sections. Mean of 2.3 ± 0.8 sizable lymph nodes were dissected and supplied by the submental artery in six cadaveric latex-injected submental flaps. All seven VSLN flaps survived. One flap required re-exploration for venous congestion but was successfully salvaged. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumference was 64 ± 11.5% above the knee, 63.7 ± 34.3% below the knee and 67.3 ± 19.2% above the ankle. CONCLUSION The transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema.

Simultaneous scarless contralateral breast augmentation during unilateral breast reconstruction using bilateral differentially split DIEP flaps.

Background: Simultaneous contralateral augmentation is performed with unilateral breast reconstruction to achieve pleasing and symmetric breast mounds. This prospective study investigated the outcome of simultaneous scarless contralateral augmentation with unilateral breast reconstruction using bilateral differentially split deep inferior epigastric perforator (DIEP) flaps. Methods: Between August of 2009 and May of 2010, six patients with a mean age of 46.2 ± 7 years underwent unilateral breast reconstruction and simultaneous contralateral augmentation using bilateral differentially split DIEP flaps. The ipsilateral internal mammary vessels served as the recipient vessels for the reconstruction split flap. The pedicle of the augmentation split flap was anastomosed to that of the reconstruction split flap in a flow-through manner. The augmentation split flap was inset through the midline with endoscopic assistance. The Modified BREAST-Q questionnaire was administered preoperatively and at the 1- and 3-month follow-up visits. Results: All flaps survived, giving a success rate of 100 percent. One reconstruction split flap required reexploration and was salvaged successfully. Mean flap weights used for reconstruction and augmentation were 410 ± 145 and 192 ± 58 g, respectively. At a mean follow-up of 12.7 ± 3.6 months, all patients were satisfied with the outcome of both reconstructed and augmented breast mounds. There were statistical improvements in breast satisfaction (p = 0.004), psychosocial function (p = 0.000), and sexual well-being (p = 0.004) postoperatively, as assessed by the Modified BREAST-Q. Conclusion: Simultaneous scarless contralateral breast augmentation can be performed safely during unilateral breast reconstruction using bilateral differentially split DIEP flaps with satisfactory outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Developing a Lower Limb Lymphedema Animal Model with Combined Lymphadenectomy and Low-dose Radiation.

Background: This study was aimed to establish a consistent lower limb lymphedema animal model for further investigation of the mechanism and treatment of lymphedema. Methods: Lymphedema in the lower extremity was created by removing unilateral inguinal lymph nodes followed by 20, 30, and 40 Gy (groups IA, IB, and IC, respectively) radiation or by removing both inguinal lymph nodes and popliteal lymph nodes followed by 20 Gy (group II) radiation in Sprague-Dawley rats (350–400 g). Tc99 lymphoscintigraphy was used to monitor lymphatic flow patterns. Volume differentiation was assessed by microcomputed tomography and defined as the percentage change of the lesioned limb compared to the healthy limb. Results: At 4 weeks postoperatively, 0% in group IA (n = 3), 37.5% in group IB (n = 16), and 50% in group IC (n = 26) developed lymphedema in the lower limb with total mortality and morbidity rate of 0%, 56.3%, and 50%, respectively. As a result of the high morbidity and mortality rates, 20 Gy was selected, and the success rate for development of lymphedema in the lower limb in group II was 81.5% (n = 27). The mean volume differentiation of the lymphedematous limb compared to the health limb was 7.76% ± 1.94% in group II, which was statistically significant compared to group I (P < 0.01). Conclusions: Removal of both inguinal and popliteal lymph nodes followed by radiation of 20 Gy can successfully develop lymphedema in the lower limb with minimal morbidity in 4 months.

Anatomical basis and clinical application of the ulnar forearm free flap for head and neck reconstruction

This study was designed to investigate the anatomical features and applications of the ulnar forearm flap in head and neck reconstructive surgery.

A novel approach to cervical reconstruction using vaginal mucosa-lined polytetrafluoroethylene graft in congenital agenesis of the cervix

OBJECTIVE To report a novel technique for cervical reconstruction in a patient with congenital agenesis of the cervix. DESIGN Case report. SETTING University-based tertiary care hospital. PATIENT(S) A woman with congenital absence of the cervix, functional vagina, and adenomyosis uteri. INTERVENTION(S) Laparoscopic-assisted creation of an uterovaginal fistula followed by placement of a polytetrafluoroethylene graft lined with vaginal mucosa graft to create the neocervix. MAIN OUTCOME MEASURE(S) Follow-up examinations with the hysteroscope confirmed unobstructed menstrual outflow through the patent neocervix. RESULT(S) The neocervix was completely mucosalized on the inner surface by 12 days postoperatively. The patient had return of menstrual bleeding at 4 weeks postoperatively. She has resumed normal sexual activities and had maintained regular menstrual cycles at the 6-month clinical follow-up. There were no complications related to the graft. CONCLUSION(S) Prosthetic reconstruction of the cervix using vaginal mucosa-lined polytetrafluoroethylene is easy to perform and effective. It offers an alternative treatment option for patients with cervical agenesis to preserve their reproductive potential.

Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability.

Background: Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion. Methods: Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale. Results: Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale. Conclusions: Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.

Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies.

The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

Use of Indocyanine Green-SPY Angiography for Tracking Lymphatic Recovery After Lymphaticovenous Anastomosis.

IntroductionLymphaticovenous anastomosis (LVA) is a surgical treatment option for patients with early stage lymphedema. To date, no ideal imaging modality exists for tracking patency of the LVA postoperatively. We hypothesize that laser angiography utilizing indocyanine green (ICG) via the SPY system (Lifecell Corp.) would be a useful methodology for assessing the patency of the LVA and lymphatic recovery postoperatively. MethodsA prospective trial was performed on patients with stage II lymphedema who underwent LVA from 2013 to 2014 by a single surgeon. All candidates underwent preoperative and postoperative lymphatic mapping using ICG-SPY angiography. Postoperative analyses were performed at 1 month and at 9 months after surgery and assessed for patency at the site of the LVAs and for changes in lymphatic pattern. ResultsFive patients underwent LVA, 3 for upper extremity and 2 for lower extremity stage II lymphedema. The number of LVAs per extremity was 1 to 3 (total, 11). One month postoperative ICG-SPY angiography demonstrated flow through 9 of 11 anastomoses. Evaluation at 9 months postoperative showed improvement in lymphatic drainage. ConclusionsIndocyanine green-SPY angiography may be used to objectively evaluate the surgical outcome of LVA.

Simultaneous left maxillary and right mandibular reconstructions with a split osteomyocutaneous peroneal artery–based combined flap

Traditionally, reconstruction of concurrent maxillary and mandibular defects on opposite sides of the facial skeleton often requires use of 2 free osseocutaneous flaps. A new technique of using a differentially split osteomyocutaneous peroneal artery–based combined (OPAC) flap for 1‐stage reconstruction of left maxillary and right mandibular defects is presented.

Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report

Thoracic duct injury can be a devastating injury with disruption of lymphatic flow leading to potentially chylothorax and/or severe lymphedema. Standard treatment modalities include thoracic duct ligation or embolization for chylothorax, but treatment options to date are few for resultant lymphedema. In this case report, we describe lymphaticovenous bypass of the thoracic duct to the jugular venous system in a 21‐year‐old male with secondary lymphedema after iatrogenic thoracic duct injury. The patient experienced improvement of lymphedema symptoms including decreased weight and limb girth as well as normalization of serum markers indicating improved lymphatic delivery to the venous system. Lymphangiogram at 3 months post op demonstrated patency of the lymphaticovenous anastomoses. At 6‐month follow‐up, the patient had returned to his preoperative level of activity and showed continued improvement of his lymphedema symptoms. Lymphovenous bypass of the thoracic duct may be an effective technique to treat secondary lymphedema from thoracic duct obstruction, though further studies are required to determine long‐term efficacy.