Kidakorn Kiranantawat

Right gastroepiploic lymph node flap

Vascularized lymph node flap transfer (VLNFT) is a tissue transfer procedure of high interest for the treatment of lymphedema. VLNFT is a new approach for treating lymphedema and during the last few years it is becoming more popular. Different donor sites for VLNFT including groin, supraclavicular, submental, thoracodorsal artery have been described. Herein, we present the results of the successful surgical management of six patients suffering from upper (2) and lower (4) limb lymphedema using a novel vascularized lymph node flap based on the right gastroepiploic (R-GE) vessels. To our knowledge, this is the first report using an intra-abdominal lymph node flap to treat lymphedema. The flap was based on the R-GE artery and vein. Harvest of the flap was performed through an upper midline laparotomy incision. The first step was to identify the right gastroepiploic vessels, then omentum was carefully dissected off the transverse colon with great care not to injure the mesocolon. The left gastroepiploic vessels were then divided and dissection of the short segmental gastric branches allowed the release of the flap from the stomach and permitted complete visualization of the R-GE vessels. Dissection was carried to the level of the right epiploic vessels. The lymph nodes within the flap cannot always be visualized but they often can be palpable. Indocyanine green lymphatic imaging could be performed to confirm the vascularity of the lymph nodes included within the flap. All patients underwent preoperative assessment, including photographs, circumference measurement, lymphoscintigraphy, and skin tonicity measurement. Microsurgical anastomoses were performed using the medial plantar vessels end-to-end and the radial artery for end-to-side anastomosis of lower and upper limb lymphedema respectively (Fig. 1). A suction drain was left in situ at the donor-site for 6 days. Patients were discharged on the tenth postoperative day. Post-operative follow-up was performed every 3 months during the first year. After 1 year follow-up all patients exhibited significant improvement and were satisfied with the functional and aesthetic results. Lymphoscintigraphy was performed and improvement was seen in all cases. No postoperative episodes of cellulitis or other complications were observed during the follow-up period. This flap has two mechanisms of function: one is the physiological lymphatic drainage from the interstitium to the vascularized lymph node flap and then into the pedicle vein, and the second is through its ability to absorb the lymphatic fluid by the omentum tissue adjacent to the vascular pedicle. Advantages of the use of this flap include the large diameter of the gastroepipolic vessels, minimal donor-site morbidity, no concern of causing iatrogenic lymphedema, and allowing a two-team approach. This flap contains omentum tissue around the pedicle that will also help in the absorption of lymphatic fluid by the affected limb. The use of laparoscopy to harvest the flap could offer a minimal insult to the abdominal wall and ensures a short and comfortable post-operative recovery period. The main disadvantage of the use of this flap includes the laparotomy required to access the lymph nodes with all of its potential complications. In lymph node flap transfer surgery, donor-site morbidity has always been a source of concern for the surgeons and patients since it is always possible for the patient to develop iatrogenic lymphedema, lymphorrea, *Correspondence to: Hung-Chi Chen, M.D., Ph.D., F.A.C.S., 2 Yuh-Der Road, Taichung, Taiwan 40447. E-mail: D19722@mail.cmuh.org.tw Received 16 June 2014; Revision accepted 18 September 2014; Accepted 10 October 2014 Published online 30 October 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22344

The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes

Lymph node flap transfer popularity for treatment of extremity lymphedema is increasing quickly. Multiple flap donor sites were described in search of the optimal one. We describe the technique and outcomes of a laparoscopically harvested right gastroepiploic lymph node flap for treatment of extremity lymphedema.

Deep Venous Thrombosis in Surgical Intensive Care Unit: Prevalence and Risk Factors

BACKGROUND Critically ill patients are at high risk for developing venous thromboembolism. The objective of this study was to determine the prevalence of, and risk factors for, lower extremity deep vein thrombosis (DVT) among critically ill surgical patients in Thailand. MATERIALS AND METHODS Patients older than 15 years who were admitted to a surgical intensive care unit (ICU) of a tertiary care hospital were enrolled. Bilateral lower extremity compression Doppler ultrasonographic examination was performed to detect DVT within 14 days of ICU admission. Demographic data, primary disease, operative intervention, co-morbidities, acute physiology and chronic health evaluation (APACHE) II score and the length of ICU stay were tested for association with the presence of DVT. RESULTS Among the 190 first-time admitted ICU patients with a mean APACHE II score of 9.2 +/- 6.0 (range, 0-29), 20 patients had DVT (prevalence of 10.5%). Thromboprophylaxis was not given to any patient. The only independent and significant risk factor for DVT was a longer ICU stay. Age, sex, APACHE II score, presence of comorbidities and operative intervention were not associated with the presence of DVT. CONCLUSION The prevalence of DVT in critically ill patients in a Thai surgical ICU was approximately 10.5%. Further research is needed to evaluate the risks and benefits of venous thromboprophylaxis in Thai patients.

A head‐to‐head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6‐year single center experience

Between 2010 and 2016, 110 patients with extremity lymphedema underwent vascularized lymph node (VLN) transfer: groin (G‐VLN = 20), supraclavicular (SC‐VLN = 54), and right gastroepiploic (RGE‐VLN = 36) open and laparoscopic approach. Herein, we discuss the pearls and pitfalls for VLN harvest and compare donor site morbidity and complications. Lymphatic leakage: G‐VLN (n = 1) and SC‐VLN (n = 1) and one hematoma: SC‐VLN were found. Laparoscopic harvest of the RGE‐VLN reduces donor site morbidity. However, surgeons experience is imperative to minimize donor site morbidity and complications. J. Surg. Oncol. 2017;115:37–42.

The combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap for breast reconstruction.

Surgical options for breast reconstruction include alloplastic and autogenous reconstructions. In autologous cases where the abdomen is not a suitable primary donor site, secondary donor sites such as the thigh or buttock are considered. The aim of this report is to describe a novel approach, the combined transverse upper gracilis and profunda artery perforator (TUGPAP) flap, aimed at medium to large volume breast reconstruction, with a single donor site used per breast.

Physical Evaluation of the Asian Blepharoplasty Patient

In contrast with Caucasian blepharoplasty, which is usually done for rejuvenation purposes, eyelid surgery for Asians is mainly done for cosmetic reasons. Here the authors present preoperative evaluation methods of Asian eyelids to overcome anatomical variations and determine the right aesthetic options. Proper selection of the most suitable operative methods guarantees optimal surgical results.

MICROSURGICAL DEBULKING PROCEDURE AFTER FREE LYMPH NODE FLAP TRANSFER

Lymph node flap transfer (LNFT) is one of the options in treating early lymphedema and its popularity is rising. Although this procedure has favorable effects on lymphedema patients, one concern is the appearance of the bulky flap on the recipient site. In the literature, it has been reported that the cosmesis of the bulky flap can be improved with de-epithelialization of the transferred flap at 12 months postoperatively. Herein, we present a debulking technique after LNFT using the microscope to achieve an optimal and safe reduction of volume for the transferred flap. Lymph node flap debulking should be done under the operating microscope to maintain the integrity of the blood vessels, for its survival and preservation of function of the transferred lymph nodes. If the vascular supply is not optimal, there is less capacity for lymph absorption into the venous system and can decrease the chance of spontaneous lymphatic regeneration after LNFT. Also in our series of patients, we preserved the skin paddle of the transferred flap due to the presence of vascular endothelial growth factors and vascular endothelial growth factor-C, expressed by distinct skin cell populations who play an important role in the molecular control of skin angiogenesis and lymphangiogenesis. In this study, 40 patients with bulky lymph node flaps received microscopic debulking procedure when the volume of the transferred lymph node flap was unpleasant to the patient after a minimum of 12 months following the initial operation. A handheld Doppler device was used to identify the pedicle of the transferred lymph node flap; its location was marked on the skin to orientate and facilitate the dissection. Under an operating microscope the skin incision was made, the capsule of the adipose tissue was opened

A comparison of vascularized cervical lymph node transfer with and without modified Charles' procedure for the treatment of lower limb lymphedema.

171e Reply: Salvage of Infected Left Ventricular Assist Device with Antibiotic Beads Sir: Professor Viroj Wiwanitkit presents an excellent discussion of studies that will improve our understanding of efficacy and safety of antibiotic beads. These include both local and systemic effects of antibiotics on tissues of the body, and the method for optimum use of antibiotic beads. With respect to antibiotic safety, all precautions that are taken with systemic antibiotics should be taken with antibiotic beads. As the professor points out, antibiotic hypersensitivity1 and antibiotic toxicity have been reported with use of antibiotic beads,2,3 whereas others have reported use without toxicity.4 As studies emerge with the use of antibiotic beads in vascular and cardiothoracic patients, often with multiple comorbidities and organ dysfunction, our understanding of the systemic consequences of their use can be better delineated. In addition, animal studies may also enable elucidation of local effects of high-dose local antibiotic therapy. Lastly, as the author mentions, there is no universally acceptable number of bead exchanges required for infection treatment.5 Empirically, cultures taken at the time of débridement drive both the type of antibiotics used and the number of débridements/exchanges needed to achieve a sterile wound before coverage.5,6 DOI: 10.1097/PRS.0000000000000270

The Asian Eyelid: Relevant Anatomy

The eyelid of Asians has its own unique characteristics. If the surgeon does not acknowledge this, aesthetically pleasing results will seldom be achieved. Here the authors review and summarize important up-to-date anatomical and relevant clinical studies of the Asian upper eyelid, aiming to help surgeons thoroughly understand its unique features, including Asian eyelid morphology, anatomical details, and the mechanisms of upper eyelid crease formation. Hopefully, an in-depth understanding of the Asian eyelid will aid surgeons to accomplish their work and lead to novel new techniques in this field.

Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel

Background: Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. Patients and methods: We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio‐venous malformation, Pagets disease, squamous cell carcinoma, and Fourniers gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. Results: All the flaps had 100% viability without partial loss. Mean follow‐up was of 7.4 months (range 4 − 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. Conclusion: The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals.