Federico Lo Torto

Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema

Vascularized lymph node (VLN) transfer for lymphedema treatment has shown promising results. Optimal donor and recipient sites remain a matter of debate. We describe the technique and outcomes of a laparoscopically harvested extended gastroepiploic VLN flap with two levels of inset.

Robotic Harvest of a Right Gastroepiploic Lymph Node Flap

Lymph node flap (LNF) transfer has proven to be an effective option in the treatment of lymphedema. As a result, much research is presently focused on finding an ideal donor site that results in good clinical outcomes while avoiding iatrogenic lymphedema of the donor area. The omental flap with its lymph nodes based on the right gastroepiploic vessels that has been described for the treatment of lymphedema in the extremities avoids donor site lymphedema of the extremities. Harvesting this flap laparoscopically further reduces the donor site morbidity [1,2]. Robotic surgery has gained popularity in numerous surgical specialties, including plastic surgery [3,4], due to its advantages over laparoscopic and endoscopic techniques. Herein, we report a novel application of robotic surgery for the harvest of a right gastroepiploic lymph node flap (RGE-LNF) for the treatment of lymphedema of the extremities. To the best of our knowledge, the application of a robotic technique for the harvest of this flap has not been reported in the literature. A 55-year-old woman presenting with left lower extremity lymphedema and unsatisfactory outcomes following conservative treatment was offered surgical management with RGE-LNF transfer. All aspects of the various options for flap harvest were explained to her, including the open, laparoscopic, and robot-assisted techniques. The patient was comfortable with the robotic option and gave consent for the Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) to be used for flap harvest (Supplemental Video S1, which demonstrates the robotic RGE- LNF harvest). An experienced general surgeon trained in robotic surgery performed the harvest of the flap with guidance from the plastic surgery team. One 12-mm supraumbilical port was created with an optical trocar for camera placement. After abdomen insufflation, two 8-mm ports were inserted at least 8 cm laterally from and 5 cm below the supraumbilical port, one on the right and the other over the left lower abdomen. Finally, a 5-mm assistance port was inserted in the epigastric region slightly cephalad to the camera port and midway between the camera and the right-side port. The RGE-LNF is based on the right gastroepiploic artery and vein (Fig. 1). Exploration was started by identifying the omental attachment to the greater curvature of the stomach and transverse colon, followed by identification of the right gastroepiploic vessels. Flap dissection was initiated by detaching the omentum from the transverse colon. The vertical gastric branches at the cranial aspect of the flap were serially ligated while maintaining a flap width of approximately 5 cm. The craniocaudal dissection was completed, keeping the flap centered on the vascular pedicle. Dissection then proceeded to the left subcostal region where the left gastroepiploic vessels were ligated. Special attention was paid to include the lymph nodes, lymphatics, and the surrounding omental tissue during the flap harvest (Fig. 2). A flap with a length of 10 cm was dissected up to the origin of the right gastroepiploic vessels, remaining parallel to the greater curvature of the stomach. Finally, the right gastroepiploic artery and vein were carefully dissected, isolated, and ligated. The total time of flap harvest was 55 minutes. The flap was then exteriorized and transferred to the lymphedematous recipient site (Fig. 3). Under the operating microscope, the flap was minimally trimmed at the margins, avoiding any damage to the lymphatic tissue witin the flap. Microsurgical anastomoses were performed at the ankle level using the medial plantar vessels in an end-to-end fashion after adequate vessel preparation (Fig. 4). The procedure was uneventful and the patient remained comfortable during the perioperative period. Fig. 1 Anatomical landmarks of the right gastroepiploic lymph node flap. The flap is based on the right gastroepiploic vessels and includes the omental tissue and embedded lymph nodes between the gastric and colonic attachment of the omentum. Fig. 2 Photograph of the surgical procedure. The robot-assisted apparatus provided three-dimensional visualization, improving the precision and the lowering risk of vascular pedicle injury. Fig. 3 The right gastroepiploic lymph node flap on a side table prior to the commencement of microanastomosis. The lymph nodes are clearly visible within the flap tissue. Fig. 4 Inset of the right gastroepiploic lymph node flap at the ankle level and microanastomosis with the medial plantar recepient vessels. The use of robotic surgery technologies, such as the Da Vinci system, has increased in various fields, and the distinct advantages of robotic surgery have been widely reported in the literature [4]. Likewise, when comparing the robot-assisted technique with the laparoscopic approach for the RGE-LNF harvest, we noted that the robot-assisted intraperitoneal approach had specific advantages. The three-dimensional optics of the Da Vinci system allowed superior visualization of the anatomy. Accurate bloodless dissection was possible due to the extremely precise platform, tremor elimination, and significant motion scaling. This was particularly important since the RGE-LNF is small, and the robotic intervention allowed preservation of the lymph nodes and the fine lymphatic channels close to the vascular pedicle. In addition, it also aided in the artery and vein dissection before the final flap pedicle division. Robot-assisted harvest of the RGE-LNF is feasible and reproducible. It represents an alternative method for flap harvest and paves the way for use of this approach for harvesting other intra-abdominal organs and tissues for reconstructive surgery. This may prove useful for patients who desire the application of the latest technology and less invasive procedures in their treatment, with the possibility of improved outcomes. It offers technical advantages over endoscopic harvesting and provides better cosmesis when compared to the open surgical technique. Some factors may limit the use of robotic interventions, such as increased cost, a steep learning curve, and increased operating time. However, the distinct advantages of this innovative surgical approach, such as tremor elimination, motion scaling, high-resolution three-dimensional optics, and superior ergonomics, make a compelling case for the expansion of its application in problem-solving specialties, including plastic and reconstructive surgery.

Delaying implant-based mammary reconstruction after radiotherapy does not decrease capsular contracture: An in vitro study☆

We read with great interest the article entitled “Delaying Implant-Based Mammary Reconstruction After Radiotherapy Does Not Decrease Capsular Contracture: An In Vitro Study (J Plast Reconstr Aesthet Surg. 2017 June; pii: S1748-6815(17)30256-5). El-Diwany et al. have published a very interesting in-vitro study about fibrosis and capsular contracture after radiotherapy (RT). In this study they demonstrated with in vitro experiments that RT causes irreversible cellular changes which permanently alter the microenvironment in favour of fibrosis so that delaying breast reconstruction does not decrease the percentage of capsular contracture. This is a very remarkable study since it shows the effects of RT on cellular and biological level and how the modifications can facilitate capsular contracture. We previously published a manuscript to evaluate the interaction between RT and the breast implants’ biomaterials and we demonstrated that no variations occurred in term of mechanical characterization and microstructural

The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck.

Reconstruction in a vessel‐depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel‐depleted neck.

The split vein graft “splint” to avoid kinking and compression of the vascular pedicle

Dear Sirs, Kinking and compression of the vascular pedicle is one of the most common causes leading to compromise of the blood flow and eventual loss of a free flap (Cheung, Zhang, Bosch, Buncke, & Lineaweaver, 1996; Kim, Kim, & Kim, 2016; Williams, French, & Lalonde, 2004). Predisposing factors include anatomic areas prone to excessive movement, effect of gravity, redundant pedicle, and length mismatch between the artery and the vein. Veins and vein grafts are especially predisposed due to the intrinsic weakness of their walls and tendency to engorge and elongate after restoration of the blood flow. Strategical positioning, cushioning with fat pads, muscle or fascia, microsurgical fixation of the vessel wall are some of the commonly employed, but of questionable efficacy, strategies as they may themselves predispose to compression. Tissue sealants have also been used, but they come at an additional cost (Kim et al., in press). We have used split vein grafts as “splints” to flatten sharp curves along the pedicle and reinforce the resistance of the vessel to compression. An appropriate length of donor vein can be harvested solely for this purpose or a remnant of greater saphenous vein graft can be employed. In our experience, saphenous vein is ideal due to its wall thickness. However, any piece of redundant vessel with suitable thickness and dimensions could be adapted for this purpose. The vein is split longitudinally and wrapped as a cuff around the area prone to kinking. The cuff can envelop the “inner vessel” either partially or completely (Figure 1a). The two edges of the venous cuff are reapproximated with fine microvascular sutures while avoiding compression of the “inner vessel.”

The radial forearm free flap as a “vascular bridge” for secondary microsurgical head and neck reconstruction in a vessel-depleted neck

In a vessel‐depleted neck, distant recipient sites may be the only option for secondary free flap reconstruction. While interposition vein grafts and arteriovenous loops can bridge the gap between the recipient and donor pedicle, they are not without risks. In these scenarios, we examinate the reliablity of a radial forearm free flap (RFFF) as an alternative vascular conduit.

New application of purse string suture in skin cancer surgery

Closure of large wounds may require full‐thickness skin grafts, but their use is burdened by donor tissue availability and morbidity; the use of the purse string technique is an elegant way to overcome this problem. The study highlights the gain in terms of graft donor site morbidity and oncological radicality. The study included a group of 47 patients who underwent surgical excision for skin cancer and whose wounds were covered using a purse string suture and a skin graft. Radius of the defect left was measured after the lesions excision and after the purse string suture. Thereafter, the difference between the initial defect area and the area after purse string suture was calculated. Initial defects ranged from 3.85 to 61.5 cm2. After skin graft, the purse string suture ranged between 2.2 and 40 cm2 (mean area = 14 cm2). Gained area before the graft measured from 1.3 to 21.5 cm2 (mean gained area = 7.1 cm2). Average reduction was 33%. The technique allows a reduction of the size of the area to be grafted and the skin graft donor area, thus increasing the possibility of the feasibility of full‐thickness grafts. In addition, it allows an optimal observation both of the area of tumour excision and margins during follow‐up controls.

“No Drain, No Gain”: Simultaneous Seroma Drainage and Tissue Expansion in Pre-pectoral Tissue Expander-Based Breast Reconstruction

Seromas represent the most frequent complication following immediate breast reconstruction surgery, in particular when acellular dermal matrix or synthetic meshes are used to add coverage to implants. Little information regarding breast seroma management is available in the literature. When seroma becomes clinically significant, current methods for its management consist of repeated needle aspiration. We report a fast, efficient, easy and riskless technique to perform serum aspiration in patients who underwent breast reconstruction with a tissue expander that allows simultaneous drainage and expansion of the implant at once. This procedure is safe, painless, does not need special supplies or additional costs and can be easily performed in ambulatory setting to manage breast seromas.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Early Markers of Angiogenesis and Ischemia during Bowel Conduit Neovascularization

Background Bowel flaps are a good and reliable method to restore the continuity of the aerodigestive tract. Radiated fields, contaminated recipient sites, or depleted recipient vessels may increase the risk for ischemic injury after transfer. During ischemic events, we believe that bowel conduits with serosa have a delayed neovascularization process at its new recipient site. We conducted an ischemia/reperfusion murine model to understand the difference among bowel conduits with and without serosa. Materials and Methods Two groups of rats were compared: control group (jejunal conduit with serosa) and a target group (jejunal conduit without serosa). These conduits were harvested from the peritoneal cavity and transferred into a subcutaneous pocket. After 72 hours of transfer and pedicle ligation, histological changes related to ischemia/reperfusion were assessed. In addition, tissue markers of angiogenesis (CD34), ischemia (lactate dehydrogenase [LDH]), and inflammation (interleukin [IL]‐1&bgr; and IL‐6) were analyzed. Results Two groups (n = 20) of male rats were analyzed. Histology showed intact jejunal mucosa in the target group. The control group showed decreased number of mucin, globet cells, decreased height, and fragmentation of villi with the absence of intestinal glands. Markers of angiogenesis (CD34) were higher in the target group. In addition, markers of ischemia (LDH) (p = 0.0045) and inflammation (IL‐1b, p = 0.0008, and IL‐6, p = 0.0008) were significantly lower in the target group as compared with the control group. Conclusions In circumstances in which the recipient site does not offer an adequate and healthy bed or a vascular insult occurs, bowel flaps with less amount of serosa may be able to neovascularize faster thereby increasing its chances of survival.

Osseointegrated Finger Prostheses Using a Tripod Titanium Mini-Plate

Background Digital amputation is a common upper extremity injury and can cause significant impairment in hand function, as well as psychosocial stigma. Currently, the gold standard for the reconstruction of such injuries involves autologous reconstruction. However, when this or other autologous options are not available, prosthetic reconstruction can provide a functionally and aesthetically viable alternative. This study describes a novel technique, known as a tripod titanium mini-plate, for osseointegrated digit prostheses, and reviews the outcomes in a set of consecutive patients. Methods A retrospective review of patients who underwent 2-stage prosthetic reconstruction of digit amputations was performed. Demographic information, occupation, mechanism of injury, number of amputated fingers, and level of amputation were reviewed. Functional and aesthetic outcomes were assessed using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale and a visual analog scale (VAS) score, respectively. In addition, complications during the postoperative period were recorded. Results Seven patients were included in this study. Their average age was 29 years. Five patients had single-digit amputations and 2 patients had multiple-digit amputations. Functional and aesthetic outcomes were assessed using the Q-DASH score (average, 10.4) and VAS score (average, 9.1), respectively. One episode of mild cellulitis was seen at 24 months of follow-up. However, it was treated successfully with oral antibiotics. No other complications were reported. Conclusions When autologous reconstruction is not suitable for digit reconstruction, prosthetic osseointegrated reconstruction can provide good aesthetic and functional results. However, larger series with longer-term follow-up are required in order to rule out the possibility of other complications.