Naoko Omori

Early diagnosis and risk factors for lymphedema following lymph node dissection for gynecologic cancer.

Background: Although early diagnosis is important for selecting an effective surgical treatment for secondary lymphedema, an efficient screening test for detecting early-stage lymphedema has not yet been established. Serial changes of lymphatic function before and after lymph node dissection and risk factors for secondary lymphedema are important indicators. Methods: A prospective cohort observational study was conducted with 100 consecutive gynecologic cancer patients who underwent pelvic lymph node dissection. Lymphatic function was assessed by noninvasive lymphography using indocyanine green fluorescence imaging on a routine schedule. Earliest findings after lymphadenectomy and risk factors for lower leg lymphedema were investigated. Results: Atypical transient dermal backflow patterns were observed in an early postoperative period in 50 cases, all of which disappeared within 3 months. Of these patterns, the splash pattern was observed in 31 patients, of which five improved to normal following a natural course. In contrast, the stardust pattern was observed in 27 patients, and none had improved with conservative therapy. Postoperative radiotherapy was a significant risk factor for the stardust pattern. Conclusions: All patients who undergo lymphadenectomy for gynecologic malignancies should be examined for secondary lower extremity lymphedema by qualitative evaluation methods on a routine schedule to determine the earliest possible diagnosis. Because the splash pattern on indocyanine green lymphography is a reversible lymphatic disorder following a natural course, surgical treatments are not recommended. The decision regarding surgical treatment can be made after observing the stardust pattern. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

A case of Crouzon syndrome treated by simultaneous bimaxillary distraction

In general, midfacial hypoplasia can be a cause of airway obstruction in patients with syndromic craniosynostosis, such as Apert syndrome and Crouzon syndrome. There have been recent reports indicating that Le Fort III midfacial distraction is effective in improvement of respiratory conditions. Our report describes a Crouzon syndrome case with repeated obstructive sleep apnea (OSA) and chronic respiratory disorder. The patient underwent not only midfacial distraction but also mandibular distraction to improve their respiratory conditions. The postoperative respiratory conditions markedly improved, and satisfactory improvements of the occlusal conditions and facial appearance were achieved. In recent years, there have been some reports in which maxillomandibular advancement or maxillomandibular distraction was performed on adults with severe OSA. However, no reports have been made on simultaneous distraction of the midface and mandible for patients with syndromic craniosynostosis. This report will present such a case in a child in whom good results were obtained. The patient was a ten-year-old boy with Crouzon syndrome, and his family history was non-contributory. During infancy, the patient underwent cranioplasty and ventriculo-peritoneal shunt surgery at the neurosurgery department. At age 2 years, he underwent Le Fort III midfacial distraction using an internal device. However, recurrence of OSA was observed. Preoperative polysomnography (PSG) showed an apnea-hypopnea index (AHI) of 29.6, and severe OSA was observed. The patient had a small mandible, narrow pharyngeal space, and severe glossoptosis during sleep. The respiratory disorder was determined to be caused by not only by maxillary hypoplasia but also by mandibular hypoplasia. Thus, Le Fort III distraction using a halo device (Blue Ddevice: W. Lorenz, Jacksonville, FL) and mandibular distraction using an internal device (W. Lorenz, Jacksonville, FL) were performed simultaneously (Figure 1). A few days after surgery, the maxilla and mandible were distracted at a rate of 1 mm per day. The amount of distraction was determined, taking into account the patient’s occlusal conditions, maxillary and mandibular solid models, and respiratory conditions which were checked on a regular basis. As a result, the midface was distracted 19 mm and the mandible 13 mm. Postoperatively, the hypoplastic midface and mandible were enlarged. The patient had an uneventful postoperative course and only slight pain with no major complications. Halo device removal and internal device removal were performed one month and six months after completion of distraction, respectively. Postoperatively, the treatment was continued with orthodontic treatment. Presently at 4 years after surgery, postoperative AHI is 4.2, indicating major improvement in the respiratory condition. Preand postoperative cephalograms were analyzed. Preoperatively, sella-nasion-subspinal (SNA)

Tissue expansion for correction of alopecia in a child with hypohidrotic ectodermal dysplasia.

chodystrophy including trachyonychia, brittleness and dryness. In a previous report, medical issues related to artificial nail coatings include hangnail, paronychia, ridging, nail discoloration, onycholysis, trachyonychia and contact dermatitis. In our case, we observed pincer nail deformity on both thumbnails and this deformity was successfully treated by nail grinding and discontinuation of the gel polishing. To the best of our knowledge, this is the first report of pincer nail deformity related to gel manicure. In conclusion, it is important that dermatologist are aware of the potential adverse effects of gel polish and should recommend the patient to stop using a gel manicure or use as infrequently as possible.

Reply: Subclinical lymphedema: understanding is the clue to decision making.

473e Reply: Subclinical Lymphedema: Understanding Is the Clue to Decision Making Sir: We appreciate the comments regarding our prospective cohort study1 on lymphatic function following lymph node dissection from Drs. Yamamoto and Koshima,2 and we agree with their opinion that patients with splash patterns in indocyanine green lymphography should be followed carefully to avoid overtreatment or delay of intervention.2 They regard such splash patterns as suggestive of subclinical lymphedema and advocate supermicrosurgical lymphaticovenular anastomosis as a treatment option; however, we disagree with this opinion at present, because lymphography results of nine (29 percent) of 31 patients in our study with a stardust pattern after a splash pattern occurred within the follow-up period. This rate was not significantly higher than that of patients with stardust patterns observed in the whole patient cohort (27 percent). In contrast, five patients (16 percent) with splash patterns improved to linear patterns and 17 others (55 percent) with splash patterns remained unchanged during the study period. The mean followup period of 11.2 months may have been extremely short to judge the outcomes of patients with splash patterns; thus, we plan to follow the patients for a longer period to determine whether those with splash patterns have a greater tendency to develop stardust patterns than others. In contrast, we believe that asymptomatic patients with stardust patterns should be classified as having subclinical lymphedema because most (11 of 14 patients, 78.6 percent) became symptomatic following conservative therapy. To determine the best timing for surgical treatment, a comparative study to confirm the effectiveness of surgical treatment for early-stage lymphedema is necessary. Usually, improvements in lymphedema can be evaluated on the basis of changes in limb size; however, limb size is highly influenced by circadian variations in early-stage lymphedema patients. Moreover, in subclinical lymphedema patients, limb size is not an important indicator of treatment effect. Therefore, treatment results should also be objectively evaluated. Indocyanine green lymphography is suitable for evaluating perioperative improvements in lymphatic function. Subsequently, it should be noted that the occurrence of a splash pattern may also improve through natural courses in at least 16 percent of patients. Treatment of subclinical lymphedema can contribute considerably to the cure of lymphedema; however, as pointed out in the Discussion of our article by Drs. Skoracki and Chang,3 intervention soon after the onset of clinical symptoms may also be a reasonable option. We have continued our cohort study without intervention for patients with linear and splash patterns on indocyanine green lymphography to evaluate the longterm treatment results, and we have initiated a nonrandomized comparative study between conservative and surgical treatments in patients who displayed stardust patterns. Further studies are required to determine the best timing for surgical treatment. DOI: 10.1097/PRS.0b013e31829acde4

Reply: Role of fluorescence lymphographic imaging in lymphedema prevention.

471e Reply: Role of Fluorescence Lymphographic Imaging in Lymphedema Prevention Sir: We appreciate the comments from Dr. Hadamitzky et al.1 regarding our prospective cohort study on lymphatic function following lymph node dissection.2 These comments encouraged us to continue further prospective analysis by including objective quantification of limb volume. In addition, in their Discussion of our article, Drs. Skoracki and Chang3 recommended that further follow-up was necessary to elucidate the long-term incidence of lymphedema and that further investigation was required to establish the exact role of indocyanine green lymphography in the diagnosis and surveillance of lymphedema. They also suggested that the diagnostic ability of indocyanine green lymphography should be compared with that of other examination methods. We agree with these suggestions and have been monitoring the patients included in our study, while adding new patients.2 Some of the cancer patients included in our study underwent chemotherapy; therefore, they experienced changes in body weight more often than healthy individuals did. Thus, an assessment method accounting for body weight that can be easily performed in an outpatient setting is necessary to accurately evaluate limb volume. The lower extremity lymphedema index described by Yamamoto et al.4 was very useful for evaluating limb volume because it is calculated from the circumferences of five defined points of the limb and body mass index. Therefore, we have been recording lower extremity lymphedema indices for the quantitative assessment of lymphedema severity. However, we should consider the best interests of the patients; therefore, clinically symptomatic lymphedema should be treated by the most adequate method. As discussed in our article, most patients with a stardust pattern in indocyanine green lymphography developed symptomatic lymphedema even if they did not display symptoms when the stardust pattern was first observed. When a patient was diagnosed with lymphedema or a stardust pattern was observed by indocyanine green lymphography, each patient was informed of the advantages and disadvantages of each surgical and conservative treatment both verbally and in writing, because it was thought to improve the outcome of early intervention.3 Consequently, we have continued our cohort study without intervention for patients with linear and splash patterns on indocyanine green lymphography to evaluate the long-term results of the study, and we have been conducting a nonrandomized comparative study between conservative and surgical treatments in patients who displayed stardust patterns. We also compared the diagnostic ability of indocyanine green lymphography with that of lymphoscintigraphy in another study.5 On the basis of our results, we recommend indocyanine green lymphography to determine patient suitability for surgical intervention, because the diagnostic ability of the test and its evaluation capability for disease severity are similar to those of lymphoscintigraphy but with lesser invasiveness and at a lower cost. In the near future, we will report our advanced results, which should provide useful information to determine long-term changes in lymphatic function, correlation between the findings of indocyanine green lymphography and objective quantification of limb volumes, and the best timing for surgical treatment. DOI: 10.1097/PRS.0b013e31829acd8f

Reconstruction of a contracted eye socket using an anterofrontal superficial temporal artery island flap and scapha composite grafting in an elderly patient

There are numerous methods for reconstruction of the eye socket. However, the use of an island flap on the forehead based on the anterofrontal branch of the superficial temporal artery has not been reported upon. This article describes an experience of eye-socket reconstruction in a 90-year-old woman with an anterofrontal superficial temporal artery island flap, a temporoparietal fascia flap and scapha composite grafting in a one-step procedure. Deep fornices were obtained and the convex eye socket was stably and easily fitted with the ocular prosthesis, which the patient started to wear 4 weeks after the operation. The socket and eyelids are without any deficits and in good condition with a 1-year follow-up.