Makoto Mihara

Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema

A new method for easy detection of functional lymphatic vessels in the superficial layer is reported. In a clinical trial, lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphaticovenular anastomoses was performed in 5 patients with lymphedema. The technique is simple and enables a minimally invasive operation to be performed. The results indicate that this technique is useful for acceptance as one of the examinations to evaluation of lymphedema.

The Intravascular Stenting Method for Treatment of Extremity Lymphedema with Multiconfiguration Lymphaticovenous Anastomoses

Background: In secondary extremity lymphedema, normal antegrade lymphatic flow is disrupted by the disease state. Attempts to capture aberrant retrograde lymphatic flow by means of microsurgical lymphaticovenous anastomoses have been hindered because of technical limitations. The authors applied the intravascular stenting method to the surgical correction of extremity lymphedema to generate multiconfiguration lymphaticovenous anastomoses capable of decompressing both proximal and distal lymphatic flow. Methods: Lymphatic channels were detected using indocyanine green injection and infrared scope imaging. Sites felt to be adequate for lymphaticovenous anastomosis were accessed through 2-cm skin incisions under local anesthesia. Using the intravascular stenting method, the authors performed a total of 39 lymphaticovenous anastomoses (15 flow-through, 11 end-to-end, eight end-to-side, two double end-to-end, two end-to-end/end-to-side, and one &pgr;-type) on both the proximal and distal ends of lymphatic channels in 14 female patients with upper (n = 2) and lower (n = 12) extremity lymphedema. Results: At an average follow-up of 8.9 months, average limb girth decreased 3.6 cm (range, 1.5 to 7 cm) or 11.3 percent (range, 4 to 33 percent). There was a greater reduction in cross-sectional area with increasing number of lymphaticovenous anastomoses per limb. Conclusions: The intravascular stenting method facilitated multiconfiguration lymphaticovenous anastomoses capable of decompressing both antegrade and retrograde lymphatic flow. This approach resulted in durable reduction of both upper and lower extremity lymphedema. As multiconfiguration lymphaticovenous anastomoses are now technically feasible, the influence of the number of lymphaticovenous anastomoses and the effectiveness of specific lymphaticovenous anastomosis configurations for the treatment of lymphedema deserves further study.

Treatment of lymphedema with lymphaticovenular anastomoses.

Although lymphedema in the extremities is a troublesome adverse effect following radical resection of various cancers, conventional therapies for lymphedema are not always satisfactory, and new breakthroughs are anticipated. With the introduction of supermicrosurgical techniques for the anastomosis of blood or lymphatic vessels less than 0.8u2009mm in diameter, we have developed a novel method of lymphaticovenular anastomosis for the treatment of primary as well as secondary lymphedema in the extremities. Here, we review the pathophysiological aspects of lymphedema, emphasizing the importance of smooth-muscle cell function in the affected lymphatic walls. We then describe the theoretical basis and detailed operative techniques of our lymphaticovenular anastomoses. Although technically demanding, especially for beginners, we believe that this method will become a new clinical standard for the treatment of lymphedema in the near future.

Intravascular stenting (IVaS) for safe and precise supermicrosurgery.

The diameter of very small vessels (about 0.5 mm or less) causes difficulties in placing forceps into the lumen and in completing anastomosis without inadvertently catching the back wall during supermicrosurgery. The insertion of nylon monofilaments into small vessels has overcome this problem. We implanted superficial inferior epigastric arterial (SIEA) flaps in 10 rats and also performed supermicroanastomosis (diameter, 0.15 mm) using SIEA flaps in mice. The back wall was never inadvertently caught using the intravascular stenting (IVaS) method, and the immediate patency rate was 100%. An advantage of using nylon for IVaS is that various sizes can be selected. We successfully anastomosed vessels with a minimum diameter of 0.15 mm. Even smaller vessels can be precisely and safely anastomosed using the IVaS method.

Digital artery perforator (DAP) flaps: Modifications for fingertip and finger stump reconstruction

UNLABELLEDnVarious fingertip reconstructions have been reported for situations where microsurgical finger replantation is impossible. One method is the digital artery perforator (DAP) flap. Herein we report 13 DAP flaps for fingertip and finger stump reconstruction following traumatic finger amputations, highlighting modifications to the originally described DAP flap.nnnMETHODSnFrom October 1998 to December 2007, a total of 13 fingers (11 patients) underwent fingertip and finger stump reconstruction with modified DAP flaps following traumatic finger amputations. We performed six adipocutaneous flaps, three adipose-only flaps, two supercharged flaps and two extended flaps. Flap size ranged from 1.44 to 8 cm(2) (average 3.25 cm(2)).nnnRESULTSnAll flaps survived completely with the exception of partial skin necrosis in two cases. One of these cases required debridement and skin grafting. Our initial three cases used donor-site skin grafting. The donor site was closed primarily in the 10 subsequent cases. No patients showed postoperative hypersensitivity of repaired fingertips. Semmes-Weinstein (SW) test result for flaps including a digital nerve branch did not differ from those without (average 4.07 vs. 3.92).nnnCONCLUSIONSnModified DAP flaps allow for preservation of digital length, volume and finger function. They can be raised as adiposal-only flaps or extended flaps and supercharged through perforator-to-perforator anastomoses. The donor defect on the lateral pulp can be closed primarily or by skin grafting. For traumatic fingertip and finger stump reconstructions, DAP flaps deliver consistent aesthetic and functional results.

Fascicular turnover flap for nerve gaps

BACKGROUNDnIt is well known that free vascularised nerve grafts have a potential for rapid axonal sprouting. However, they are not very popular as the surgical techniques are complicated. With the recent development of supramicrosurgical techniques and microanatomy of nerve trunks, a new method, fascicular turnover method, using vascularised fascicular flap was used for repairing nerve gaps. METHODSAND RESULTS: Arterial embalming method, using rat sciatic nerves, was employed to observe fascicular micro-vascularisation. Rich vascular network systems were observed within and outside the rat island nerve flaps. Four cases with digital and facial nerves gaps were repaired with fascicular turnover flap without a nerve graft. Three patients had digital nerve gaps (10-20mm in length) and one had a 3-cm facial nerve gap. The results of sensory recovery of digital nerve gap were 3.22-3.66 (Semmes-Weinstein values) and 6-12mm (moving two-point discriminations) at 6 and -16 months after surgery, respectively.nnnCONCLUSIONnThe advantages of this method are: retention of the normal donor nerve, a shorter operation time and repair of the digital nerve gaps under local anaesthesia. Fascicular flap is a vascularised nerve flap with fast and accurate nerve sprouting in comparison to a non-vascularised graft. Excellent nerve regeneration can be expected even in cases with longer nerve gap and scarred recipient bed. It is a simple and quick surgery compared to free vascularised nerve flaps. In addition, there is no functional loss because of the sacrificed fascicle in the operated area. The only disadvantage is the need to employ superficial palmar branch of radial artery (SPRA)-microsurgical techniques using a 50-micron needle.

Intravascular stenting (IVaS) method for fingertip replantation.

Remarkable progress has been made in microsurgery. However, fingertip replantation following amputation has not gained much popularity because of its technical difficulty. We have developed the intravascular stenting (IVaS) method, in which a nylon monofilament is placed inside the vessel lumen to act as a temporary stent, facilitating anastomosis completion. This report describes 7 fingertip replantations using the IVaS method. Intravascular stent size varied from 4-0 to 6-0 (0.199–0.07 mm diameter). There were no cases in which the back wall of a vessel became inadvertently caught in the anastomosis. The overall survival rate for distal digital replants was 85% (6/7 replants). It is very difficult to evenly anastomose vessels of differing diameter, especially on a supermicrosurgical scale. In this respect, the IVaS method plays a role in stably anchoring the 2 vessel ends, allowing for the even spacing of suture knots, even in vessels of different caliber. Because of its ease of use and exactitude, many surgeons may be able to use the IVaS method to reliably complete small anastomoses in fingertip replantations.

Cross-face nerve transfer for established trigeminal branch II palsy.

Reconstruction for trigeminal nerve II palsy is challenging. Cross-face nerve transfer from the contralateral trigeminal nerve facilitates this reconstruction. However, the microanatomy and techniques required for nerve sutures cause problems for many surgeons. Following the recent development of supramicrosurgical techniques appropriate for the microanatomy of peripheral nerves, a new method of intraoral cross-face nerve transfer was successfully used for repairing trigeminal nerve II palsy. Two cases of trigeminal nerve II palsy were repaired with contralateral trigeminal nerve transfer without any nerve graft. Affected upper labial sensory recovery was 1.65 to 2.44 (Semmes-Weinstein values) and 15 to 30 mm (moving 2-point discriminations) at 1 to 1 1/2 years after surgery. The advantages of this method are excellent nerve regeneration and the lack of donor site morbidity. It is a brief and simple operation in comparison to free nerve grafts. The disadvantage is a need for a supramicrosurgical technique, using a needle less than 80 microm wide.

Short pedicle thoracodorsal artery perforator (TAP) adiposal flap for three-dimensional reconstruction of contracted orbital cavity *

SUMMARY BACKGROUNDnEye socket reconstruction for orbital contracture after removal of retinoblastoma remains challenging, because it is often accompanied by atrophy of facial soft tissue, malar bone and temporal muscle.nnnCASE DESCRIPTIONnA 45-year-old woman with a contracted eye socket underwent reconstructive surgery with a trilobed thoracodorsal artery perforator (TAP) adiposal flap with skin island. The flap was successfully transferred to expand the eye socket and augument hypoplastic facial tissue. A short pedicle TAP adiposal flap through the mid-axillary line was obtained with the patient in a supine position. The T portion of the lateral intramuscular branch was transected as a pedicle vessel and flow-through vascular anastomosis was carried out.nnnCONCLUSIONnTAP adiposal flap obtained with the patient supine is very useful for reconstruction of the eye socket, eyelid, temporal muscle, and malar tissue. The advantages of the short pedicle TAP flap are that it is minimally invasive, can be transferred with only a lateral muscular branch of the thoracodorsal system, and preserves the main trunk of the thoracodorsal artery and nerve and the branch to the serratus anterior. Flow-through vascular anastomosis is possible and the flap can be harvested without the need for secondary debulking.