Mouchammed Agko

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.

Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema.

This study evaluated the long‐term clinical outcomes among different vascularized lymph node transfers (VLNT) used at our institution.

Vascularized appendicular lymph node transfer for treatment of extremity lymphedema: A case report

Vascularized lymph node transfer has demonstrated promising results for the treatment of extremity lymphedema. In an attempt to find the ideal donor site, several vascularized lymph nodes have been described. Each has a common goal of decreasing morbidity and avoiding iatrogenic lymphedema while obtaining good clinical results. Herein, we present the preliminary clinical outcomes of an intra‐abdominal lymph node flap option based on the appendicular artery and vein used for the treatment of extremity lymphedema. A 62 year‐old woman with moderate lower extremity lymphedema, on chronic antibiotics because of recurrent infections and unsatisfactory outcomes after conservative treatment underwent a vascularized appendicular lymph node (VALN) transfer. At a follow‐up of 6 months, the reduction rate of the limb circumference was 17.4%, 15.1%, 12.0% and 9% above the knee, below the knee, above the ankle and foot respectively. In addition, no further episodes of infection or other complications were reported after VALN transfer. Postoperative lymphoscintigraphy demonstrated that the VALN flap was able to improve the lymphatic drainage of the affected limb. According to our findings, the use of VALN transfer minimizes donor‐site morbidity, avoids iatrogenic lymphedema and may provide a strong clearance of infection because of the strong immunologic properties of the appendiceal lymphatic tissue in selected patients. Despite these promising results, further research with larger number of patients and longer follow‐ up is needed.

Histo-anatomical basis of the gastroepiploic vascularized lymph node flap: The overlooked “micro” lymph nodes

Microsurgical treatment of lymphedema in the form of autologous vascularized lymph node (VLN) transfer is increasingly accepted as an effective method, since it reduces limb size and infectious episodes. To date, a multitude of flaps have been described so far, but there is no consensus on specific flap choice. After using the groin and supraclavicular VLN flaps for many years, we investigated alternative sites with potentially less donor site morbidity. The gastroepiploic VLN flap was one of the flaps that we explored. It is a modification of the free omental flap described several decades ago for the treatment of lymphedema. The omental tissue harvested is limited to the area adjacent to the gastroepiploic vascular arcade, as the lymph nodes are located around the vessels. Nguyen et al. have shown that there is a direct correlation between the number of transferred lymph nodes and the improvement in lymphatic function. In this regard, the lymph node content of the gastroepiploic VLN flap has not been specifically elucidated within the lymphedema surgery literature. The purpose of this communication is to present the anatomical basis of the gastroepiploic VLN flap and highlight the existence of “micro” lymph nodes. The topography of the perigastric nodal basins has been extensively investigated as related to lymphadenectomy for gastric cancer. According to the widely accepted Japanese classification, the nodal tissue around the gastroepiploic arcade is defined as nodal station no. 4. This is further subdivided to 4s (sinistri) and 4d (dextri) referring to the left and right gastroepiploic lymph nodes, respectively. To determine the number of lymph nodes in each nodal basin, Borchard et al. used a microscopic serial section technique in 10 adult cadavers without gastric cancer. After fixation, 1 cm-wide strips of stomach wall, together with 3 cm of the adjacent omentum, were embedded in

Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report

Vascularized lymph node (VLN) transfer has been of high interest in the past decade for the treatment of lymphedema, since it has been shown to be effective in reducing limb volumes, decreasing infectious episodes and improving quality of life. Multiple donor sites have been described in the quest for the optimal one. Herein, we describe a novel lymph node flap option based on the ileocolic artery and vein. The ileocecal vascularized lymph node (IC‐VLN) flap was used in the management of a 33‐year‐old male patient with lower extremity lymphedema secondary to left inguinal trauma. The patient had previously underwent a pedicled omentum flap transposition with minimal improvement in limb size and persistent episodes of infection. At 15 month follow‐up, the IC‐VLN flap improved the lymphatic drainage in the affected limb with a mean limb circumference reduction rate of 26.3%. No donor site complications or further episodes of infection were noted. According to our findings, the IC‐VLN flap may be another option for VLN transfer in very selected cases. Nevertheless, larger series with a longer follow‐up are required to analyze the efficacy and long‐term results of this flap.

Do Not Fear an Implant’s Shape: A Single Surgeon’s Experience of Over 1200 Round and Shaped Textured Implants in Primary Breast Augmentation

Background Breast implants can be characterized by their fill material, surface texture, or shape. Whereas long-term good quality studies have provided evidence for the fill material and texture, there is still little consensus for choosing the shape of an implant. Surveys indicate that many surgeons choose only one implant shape, for reasons that may not always agree with outcomes from long-term studies. Objectives We reviewed the first authors experience over the last six years with both round and anatomical implants, compared the rate of complications with either implant shape, and discussed the importance of keeping an open mind about using both implant shapes for primary breast augmentation. Methods A review of all consecutive primary breast augmentation patients by the first author over a six-year time period who had a minimum follow up of 6 months after surgery. Results Six-hundred and forty-eight female patients had 1296 silicone breast implants inserted over the six-year period. Mean age at surgery was 30.5 years and mean BMI was 20.6 kg/m2. All implants were textured, 134 (in 67 patients, 10.3%) were round in shape with mean volume of 338 cc (range, 220-560 cc), while 1162 implants (in 581 patients, 89.7%) were anatomical shaped with a mean volume of 309 cc (range, 140-615 cc). Among these patients, 11.9% (n = 8) with round implants and 9.0% (n = 52) of those with anatomical implants developed complications postoperatively. Conclusions A single, ideal implant that is suitable for every primary breast augmentation does not exist. The optimum choice of implant shape in any given situation should take into account the patients physical characteristics, available implant types, patients desires, and the surgeons experience. Together with round implants, anatomical devices ought to be considered as one of the tools in the surgeons toolbox. By choosing to ignore them a priori means that the surgeon will only have access to half of his armamentarium and will therefore be able to offer a limited set of options to his patients. Level of Evidence 4

Laparoscopic harvest of ileocolon flap in pharyngoesophageal reconstruction.

Dear Sir, The ileocolon flap is a well-known technique used for pharyngoesophageal reconstruction (Perrone et al., 2013). The cecum and part of the ascending colon are used to reconstruct the esophagus, while a segment of the terminal ileum is connected to the trachea, shunting air from the main airway to the neo-esophagus and making it resonate (Lo Torto et al., in press). Traditionally, it is a major procedure requiring a laparotomy and usually a long postoperative hospitalization. The aim of this letter is to report the first laparoscopic harvest of ileocolon flap for pharyngoesophageal reconstruction. Pharyngolaryngectomy with immediate reconstruction using an ileocolon flap was planned for a 57-year-old patient presenting with hypopharyngeal cancer (Figure 1A). The flap harvest was performed laparoscopically through 4 trocars. The intestines were mobilized from the terminal ileum up to the transverse colon. After division of the ileocolic pedicle and the right branch of the middle colic artery, the umbilical port was enlarged to deliver the specimen (Figure 1B). The proximal and distal ends of the flap were divided and intestinal continuity was restored with a functionally end-to-end stapled ileocolonic anastomosis. The recipient vessels for revascularization of the flap were the thoracoacromial artery and cephalic vein, as no other suitable vessels were found in the neck. The flap was inset in an isoperistatltic fashion. The cecum was anastomosed to the pharyngeal stump superiorly, while the asccending colon was anastomosed to the upper end of thoracic esophagus inferiorly. The ileal segment of the flap was then used for voice reconstruction with anastomosis to the side of tracheal stump. The total operative time was six hours including the one hour spent for the laparoscopic harvest of the flap. The postoperative course was uneventful. The patient was discharged at one month after tolerating oral feeding. Voice rehabilitation was initiated at 2 months. No perioperative donor or recipient site complication was noted. While the free ileocolon flap provides simultaneous restoration of speech and swallowing function, the traditional open approach might be associated with high donor site morbidity (Karri et al., 2011). The laparoscopic harvest can be a promising alternative that can avoid a large abdominal wound with its associated potential complications and decrease pain and hospitalization time (Ding et al., 2013). This is very important in this patient group due to their short life expectancy (Beauvillain et al., 1997). Laparoscopic harvesting of ileocolon flap is expected to provide all the advantages of a minimally invasive

Implementation of an Integrated Biodimensional Method of Breast Augmentation with Anatomic, Highly Cohesive Silicone Gel Implants: Short-Term Results With the First 620 Consecutive Cases

Background: The previously described Akademikliniken (AK) method is a comprehensive approach to breast augmentation with form stable implants that has been shown to afford favorable outcomes when applied by experienced surgeons. Objectives: To evaluate outcomes of a surgeon newly adopting this method at the beginning of his career. Methods: A retrospective review of patients undergoing dual plane subpectoral augmentation with Style 410 implants between April 2009 and December 2014 was undertaken. The review was performed one year after the last operation. The first author (P.M.) performed all operations. Complications and reoperation rates were analyzed and correlated with patient and implant characteristics using the chi‐square or Fishers exact test, as appropriate. Results: A total of 620 consecutive patients met the inclusion criteria with a mean follow up of 8 months (range, 1 week‐60 months). Complications occurred in 14.8% of the patients: request for larger size (3.3%), rotation (3%), and Baker III/IV capsular contracture (2.2%) were the most common ones. Low implant projection was a statistically significant risk factor (P < 0.05) for the most common complication ‐ request for a larger size. The overall reoperation rate was 8.7%. The most common indication for reoperation was request for larger size (2.2%) followed by rotation (2.2%) and capsular contracture (2%). Conclusions: Breast augmentation with form stable anatomical implants requires a considerably different process. By implementing a systematic approach such as the AK method, novices in this terrain can expect to achieve reasonable outcomes. Level of Evidence: 4 Figure. No caption available.

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation

Background: Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero‐anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases. Objectives: To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations. Methods: All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero‐anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere. Results: A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture. Conclusions: This reliable technique provides stable results as shown by low rate of complications with the existing follow up. Level of Evidence: 4 Figure. No caption available.

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.