Nobuko Hayashi

Arm Volumetry Versus Upper Extremity Lymphedema Index: Validity of Upper Extremity Lymphedema Index for Body-type Corrected Arm Volume Evaluation

BackgroundVolumetry, measurement of extremity volume, is a commonly used method for upper extremity lymphedema (UEL) evaluation. However, comparison between different patients with different physiques is difficult with volumetry, because body-type difference greatly affects arm volume. MethodsSeventy arms of 35 participants who had no history of arm edema or breast cancer were evaluated. Arm volume was calculated using a summed truncated cone model, and UEL index was calculated using circumferences and body mass index (BMI). Examinees’ BMI was classified into 3 groups, namely, low BMI (BMI, <20 kg/m2), middle BMI (BMI, 20–25 kg/m2), and high BMI (BMI, >25 kg/m2). Arm volume and UEL index were compared with corresponding BMI groups. ResultsMean (SD) arm volume was 1090.9 (205.5) mL, and UEL index 96.9 (5.6). There were significant differences in arm volume between BMI groups [low BMI vs middle BMI vs high BMI, 945.2 (107.4) vs 1045.2 (87.5) vs 1443.1 (244.4) mL, P < 0.001]. There was no significant difference in UEL index between BMI groups [low BMI vs middle BMI vs high BMI, 97.2 (4.2) vs 96.6 (4.6) vs 96.7 (9.9), P > 0.5]. ConclusionsArm volume significantly increased with increase of BMI, whereas UEL index stayed constant regardless of BMI. Upper extremity lymphedema index would allow better body-type corrected arm volume evaluation compared with arm volumetry.

Ultrasound visualization of the lymphatic vessels in the lower leg.

Identification of lymphatic vessels for lymphaticovenular anastomosis (LVA), which is an effective surgical treatment for obstructive lymphedema, is important. Indocyanine green (ICG) lymphography is useful for that purpose, but is not common in many institutions. Although ultrasound is a very common modality, no research has yet underlined the feasibility of the device to detect the lymphatic vessels.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type–Corrected Lower Extremity Volume Evaluation

BackgroundVolume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV). MethodsTwenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20–25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups. ResultsThe mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m2, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m2, P < 0.001]. ConclusionsThe LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type–corrected LV evaluation compared with volumetry-based evaluations.

Correlation between indocyanine green (ICG) patterns and real-time elastography images in lower extremity lymphedema patients

BACKGROUND/AIM Indocyanine green (ICG) lymphography is becoming a popular modality, but unfortunately it is not available in all institutions. Elastography is a relatively new ultrasonographic technique to evaluate tissue elasticity, which visualizes fluid retention as a red region in lymphedema patients. The aim of this study was to evaluate the correlation between elastography and ICG lymphology. METHODS Thirty-six legs in 18 patients with secondary lower extremity lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined using elastography. Thirty-six legs in 18 secondary LEL patients were examined using ICG lymphography. Elastography was performed on both legs at the following three sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of the red region in the subcutaneous tissue demonstrated by elastography was calculated using Image software. ICG lymphography findings were classified into the following four patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns. RESULTS As ICG pattern progressed, the red region area was likely to increase. There was a correlation between ICG patterns and red region area according to the severity at bilateral MT (rs = 0.665), ML (rs = 0.623), and AA (rs = 0.668). Significant difference was demonstrated among group means of the red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 ± 5.7 vs. 15.1 ± 10.3 vs. 25.2 ± 6.2 vs. 30.8 ± 9.4 vs. 35.0 ± 2.8; P < 0.001). CONCLUSIONS The area of the red region in the subcutaneous tissue shown using elastography, which represents fluid, increases with the aggravation of lymphedema demonstrated by ICG patterns. As elastography is performed by ultrasonography, which is available in most institutions, elastography could be a useful alternative evaluation for lymphedema severity when ICG lymphography is not available.

Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema

Identification of functional lymphatic vessels and localization of lymphatic vessels are important for lymphaticovenular anastomosis (LVA). Indocyanine green (ICG) lymphography is useful for localization of superficial lymphatic vessels where dermal backflow is not observed, but not for lymphatic vessels in deep layer or where dermal backflow is observed. Ultrasound has been applied in LVA and is considered useful for localization of lymphatic vessels with ICG lymphography cannot be visualized.

Ultrasound-Assisted Lymphaticovenular Anastomosis for the Treatment of Peripheral Lymphedema

1. Rome, Italy Department of Plastic and Reconstructive Surgery, Università Cattolica del “Sacro Cuore” – University Hospital “A. Gemelli” 2. Tokyo, Japan Plastic Surgeon, Department of Plastic and Reconstructive Surgery, Tokyo Metropolitan Bokutoh Hospital 3. Chiba, Japan Department of Plastic Surgery, Asahi General Hospital Corresponding Author: Akitatsu Hayashi, M.D. Address: 1326, I, Asahi, Chiba, 289-2511, Japan. Tel: +81-479-63-8111, Fax: +81-479-62-3757 E-mail: promise_me_now65@yahoo.co.jp AC CE PT ED

Reconstruction of the ankle complex wound with a fabricated superficial circumflex iliac artery chimeric flap including the sartorius muscle: A case report

Free flap reconstruction of the foot and ankle can be challenging in that it must fulfill functional and esthetic demands. Injury of this region is often associated with fractures, and muscle flaps are sometimes preferred. Here we present a case of the use of superficial circumflex iliac artery (SCIA) chimeric flap for reconstruction of ankle complex wound. A 78‐year‐old lady sustained open fractures of the left distal tibia, fibula, and talus, with a 10 × 6 cm2 soft‐tissue defect over the lateral aspect of her left ankle due to an automobile accident. A 7 × 3 cm2 sartorius muscle component was inset to cover the exposed left ankle joint capsule, and a 5 × 10 cm2 SCIP skin paddle was used for coverage of the defect. The postoperative course was uneventful, and the sartorius muscle component and the SCIP skin paddle survived completely. Six months after the reconstruction, the flap and the donor site showed pleasing cosmesis, and the patient could ambulate with a supple ankle without crutches. The sartorius muscle component was elevated based on the deep branch of the SCIA, and was chimerically combined with a SCIP skin paddle for reconstruction of a complex ankle injury.

A Combined Microsurgical Reconstruction Approach for Lymphedema

For the successful performance of microsurgical lymphatic surgery for lymphedema, it is important to identify functional lymphatic vessels and determine the location of lymphatic vessels preoperatively. Combination of microsurgical lymphatic surgery and preoperative using medical equipment (direct method, physiologic method, and indirect method) enables more precise and efficient microsurgery.

Dermoid Cyst with Fistula on the Dorsum of the Tongue

Abstract A 32-year-old woman presented with difficulty in swallowing and swelling of the tongue. A fistula was seen on the dorsum of the tongue. As T2-weighted magnetic resonance imaging showed a high signal intensity lesion with poorly defined margins, a provisional diagnosis of tongue lipoma or angiomyolipoma was made. The lesion was surgically removed including the fistula. Sebaceous glands were seen in the epithelial lining on histopathological analysis, which suggested a dermoid cyst. The patients postoperative course was satisfactory, and no recurrence has been observed during 18 months of follow-up after surgery.