Seong Yoon Lim

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.

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

End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle.

BACKGROUND Although perforator-to-perforator anastomosis in supermicrosurgery may be used in transferring free flaps with small vessels, it is still difficult in certain situations that include potentially infected wounds. Moreover, it is limited to smaller flaps. Anastomosis of large vessels is still safer for transfer of a large flap for most surgeons. The harvesting of a patch of the parent artery together with the perforator supplying the flap allows the surgeon to perform an anastomosis between the vessel ends of larger caliber, and possibly with greater anastomotic success. METHOD When the vascular pedicle of a free flap is < 0.8 mm, an option is to take a cuff of the major artery for an end-to-patch anastomosis. From 1983 to 2013, this method was applied to the anteromedial thigh (AMT) flap (seven cases), the groin flap (81 cases), and the free Beckers flap (five cases). When a patch was taken from the femoral artery, direct anastomosis for the major artery was performed using 5/0 Prolene sutures, followed by coverage with local soft tissue. When a patch was taken from the ulnar artery, a patch of vein graft was used for repair of the ulnar artery. In one case, a segment of the femoral artery was harvested with an AMT flap and a segment of a sartorius muscle flap; the compound tissue was transferred to the neck with the femoral artery to replace the left carotid artery. In the donor site, the defect of the femoral artery was reconstructed with an artificial graft. RESULTS The flaps had no failure or partial necrosis, but one patient developed bleeding from the femoral artery 2 days postoperatively. It was treated by adding one more suture for the femoral artery and coverage with the sartorius muscle. In the ulnar artery, the patients did not complain of cold intolerance and the postoperative angiogram showed good patency of the ulnar artery after an average follow-up of 1 year. CONCLUSION For the majority of plastic surgeons, this method provides a reliable and comfortable anastomosis when transferring a flap with small vessels. The only concern is to repair the donor artery carefully and ensure coverage of the repair site with local tissue.

Reconstruction after orbital exenteration using gracilis muscle free flap.

Orbital exenteration (OE) is a disfiguring procedure, which typically includes the removal of the entire eyeball including the globe, extraocular muscles, and periorbital soft tissues after malignancies excision or trauma. Several methods of orbital reconstruction have been attempted with varying success. In this report, we analyze results of the use of gracilis muscle free flap for reconstruction of OE defects and its feasibility for prosthetic rehabilitation.

A novel “continuous-interrupted” method for microvascular anastomosis: Letter to the Editor

The conventional method of microvascular anastomosis with interrupted sutures is well proven method, with high successful rate. However, this method is time consuming, especially when multiple anastomosis are required. Even though several techniques have been described to minimize the time of anastomosis, none of these have been widely accepted. Vessel anastomosis with a continuous suture has the advantage of being faster than the conventional method but due to the high risk of stricture at the anastomotic site is not recommended for microvascular anastomosis. Herein, we present a novel method of performing microvascular anastomosis, which combines the advantages of the continuous and interrupted sutures. After proper setup of the vessels, the anastomosis begins with the application of two 10-0 sutures at 0 and 180 angle (Fig. 1A). Then a loose running suture is applied at the anterior wall of the vessel. Depending on the size of the vessel, usually 3 to 4 passes of the suture are required, creating 2 or 3 loops, respectively. (Figs. 1B and 1C) Then the end of the first suture is tied with the corresponding suture of the opposite site and the knot is cut leaving one suture-loop less (Figs 1D and 1E). The same procedure is repeated for the rest sutures as well as at the posterior vessel wall (Figs. 1F and 1G). We performed this technique in 30 venous and 15 arterial anastomoses during free tissue transfer. In 15 free flaps, both the arterial and venous anastomoses were performed with the described method, meanwhile in other 15 free flaps, the arterial anastomoses were performed with the conventional method and the venous anastomosis with the “continuous-interrupted” technique. In both of the groups, no complications were noted performing this technique as all the flaps survived well. Furthermore, the same surgeon in anterolateral thigh flap (ALT) flaps performed 20 venous anastomoses, 10 with the conventional technique, and 10 with the proposed method in order to compare the time difference between the two methods in vessels with the same size. Statistically significant less time was required (P< 0.05) for the venous anastomosis with the “continuous-interrupted” method. The described method for microvascular anastomosis has several advantages. First of all, the application of the sutures can be very precise as the loosely running suture leaves spaces between the vessels, allowing the lumen to be visible without extensive manipulation of the vessel. This is very useful especially when the last suture of the anterior and posterior wall is applied, which with the conventional method there is limited space between the two edges of vessels. Similarly, during the anastomosis, the posterior vessel wall is always visible, avoiding inadvertent two-wall sewing. Additionally, even though the suture is applied continuously, finally tied as the interrupted fashion, hence there is no risk of stenosis at the anastomotic site. Finally, the anastomosis is performed faster than the conventional method, as the surgeon saves time applying the sutures with a running manner. *Correspondence to: Stamatis Sapountzis, Department of Plastic Surgery, China Medical University Hospital/, China Medical University, 2, Yuh-der Road, Taichung, Taiwan. E-mail: ssapountzis@yahoo.com Received 16 May 2013; Accepted 19 July 2013 Published online 13 September 2013 in Wiley Online Library (wileyonlinelibrary. com). DOI: 10.1002/micr.22174

Potential Use of Transferred Lymph Nodes as Metastasis Detectors after Tumor Excision

Due to the fact that it reliably results in positive outcomes, lymph node flap transfer is becoming an increasingly popular surgical procedure for the prevention and treatment of lymphedema. This technique has been shown to stimulate lymphoangiogenesis and restore lymphatic function, as well as decreasing infection rates, minimizing pain, and preventing the recurrence of lymphedema. In this article, we investigate possible additional benefits of lymph node flap transfer, primarily the possibility that sentinel lymph nodes may be used to detect micro-metastasis or in-transit metastasis and may function as an additional lymphatic station after the excision of advanced skin cancer.

Transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction.

Neurogenic blepharoptosis related to orbital surgery is very rare and only 1 report was published in the literature. This report presents 1 case of transient and isolated neurogenic blepharoptosis after medial orbital wall reconstruction. A 12-year-old male patient who suffered from periorbital trauma visited our hospital with right periorbital pain. During the physical examination, mild ecchymosis and eyelid edema were reported; however, there were no signs of either limitation of ocular motion or anisocoria. On the orbital CT images, a 17 mm × 20 mm-sized medial orbital bony defect was observed and the medial rectus muscle and orbital fat were herniated. The operation was performed 12 days after injury and the transcaruncular approach was used to reach the medial orbital wall. After the operation, he had right side blepharoptosis with mild eyelid edema and ecchymosis. However, ocular movement was normal and there were no signs of anisocoria. He did not receive any additional medication for blepharoptosis and was discharged 3 days postoperation. By the ninth day of postoperative recovery, the patient still suffered from right blepharoptosis with no levator palpebrae superioris muscle function. We prescribed a low dose of oral corticosteroid and the patient was monitored on a weekly basis. Finally, he recovered completely with normal symmetric eyelid position and levator function.

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.

Lymphedema Fat Graft: An Ideal Filler for Facial Rejuvenation

Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.