Improving quality of life after breast cancer: a comparison of two microsurgical treatment options for breast cancer-related lymphedema (BCRL)

PURPOSE

Vascularized lymph node transfer (VLNT) entails the autologous relocation of lymph nodes to a lymphedematous region of the body, whereas lymphaticovenous anastomosis (LVA) creates a direct bypass between the lymphatic and venous system. Both techniques are meant to lastingly bolster the local lymphatic drainage capacity. This study compared safety and effectiveness of VLNT and LVA in patients with chronic breast cancer related lymphedema (BCRL).

METHODS

A retrospective cohort study was conducted using data from our encrypted database composed of patients with chronic BCRL who were treated with either VLNT or LVA and had a minimum follow-up of two years. Patient-specific variables analyzed included pre- and postoperative arm circumferences, lymphedema stages and postoperative complications.

RESULTS

A total of 105 patients met the inclusion criteria, of which 96 patients demonstrated a complete follow-up period of two years. The VLNT group displayed larger preoperative circumferential measurements, evident in both in the isolated examination of the affected arm, as well as when adjusted for the contralateral unaffected arm. Significant reduction in arm volume was achieved by both groups. However, VLNT demonstrated superior relative reduction rates than LVA, neutralizing any significant arm size disparities after 24 months. Surgery duration was slightly longer for VLNT than LVA. Postoperative complications, predominantly minor, were exclusively observed in the VLNT group.

CONCLUSIONS

Both VLNT and LVA offer significant improvement for patients suffering from chronic BCRL. VLNT shows an even greater potential for improvement in more severe cases of BCRL, but involves a higher risk for (mostly minor) complications.

Lymphaticovenous anastomosis in rabbits: A novel live experimental animal model for supermicrosurgical training

BACKGROUND

Lymphaticovenous anastomosis is widely used in lymphedema management. Although its effectiveness in reducing edema in patients can be clinically observed, evaluating the long-term outcomes of this technique can be complex. This study established an animal model to assess the outcomes of lymphaticovenous anastomosis technique at 15 and 30-days post-surgery using indocyanine green lymphography, Patent Blue V dye injection, and histopathological examination.

METHODS

An experimental model was established in the hindlimbs of 10 rabbits using the popliteal vein and afferent lymphatic vessels in the popliteal area. The subjects were divided into two groups: the first group (n = 5) underwent patency assessment at 0 and 15 days, and the second group (n = 5) at 0 and 30-days, resulting in 20 anastomoses. Patency was verified at 0, 15, and 30-days using indocyanine green lymphography and Patent Blue V injection. Histopathological examinations were performed on the collected anastomosis samples.

RESULTS

The patency rate was 90% (19/20) initially, 60% (6/10) at 15 days post-surgery, and 80% (8/10) at 30-days. The average diameter of lymphatic vessels and veins was 1.0 mm and 0.8 mm, respectively. The median number of collateral veins was 3; the median surgical time was 65.8 min. Histopathology revealed minimal endothelial damage and inflammatory responses due to the surgical sutures, with vascular inflammation and thrombosis in a single case. Local vascular neoformations were observed.

CONCLUSION

This study highlights the reliability and reproducibility of using rabbits as experimental models for training in lymphaticovenous anastomosis technique owing to the accessibility of the surgical site and dimensions of their popliteal vasculature.

100 anastomoses: a two-year single-center experience with robotic-assisted micro- and supermicrosurgery for lymphatic reconstruction

Robotic-assisted microsurgery has gained significant attention in recent years following the introduction of two dedicated microsurgical robotic systems specifically designed for this purpose. These feature higher degrees of movement and motion scaling which are useful tools, especially when performing surgery in areas of the body which are difficult to access. Robotic-assisted microsurgery has been implemented in lymphatic surgery as well as soft tissue reconstructive surgery at our institution over the past 2.5 years. Our study gives an insight into the details and outcomes of the first 100 consecutive (super-) microsurgical anastomoses in peripheral and central lymphatic reconstruction performed with the Symani® Surgical System between 2021 and 2024. In total, 67 patients were treated, receiving robotic-assisted lymphatic reconstruction with lymphatic tissue transfer (LTT) and/or lymphovenous anastomoses (LVA)/lympholymphatic anastomoses (LLA). No anastomosis-associated complications were recorded postoperatively. The majority of patients reported a postoperative improvement of their lymphedema or central lymphatic disorder. In conclusion, we show the successful implementation of the Symani® Surgical System into our clinical practice of lymphatic reconstruction. Although the necessary intraoperative setup and the use of intrinsic motion scaling lead to a slight increase in operating time, the presented study demonstrates the advantages of robotic assistance which becomes particularly evident in lymphatic surgery due to the involved deep surgical sites and the need for supermicrosurgical techniques.

Replantation of digit-tip amputation caused by crush injuries with supermicrosurgery technique

PURPOSE

Digit-tip amputation caused by crush injury is a common emergency scenario, and the management is full of challenges. The objective of this study was to demonstrate the application of the supermicrosurgery technique in replantation procedures for complex digit-tip amputations resulting from crush injuries, while also assessing functional and aesthetic outcomes.

METHODS

We conducted a retrospective analysis of the data from 12 patients who underwent replantation of 15 digits in our department between July 2022 and June 2023. The outcomes of replantation, functional recovery (including return to work, cold tolerance, bone union, DASH score, VAS score, and two-point discrimination test), aesthetic results (including digit appearance, nail deformity, and pulp atrophy), and patient satisfaction were assessed.

RESULTS

The amputation of 7 digits occurred within Tamai zone I level, 8 digits within Tamai zone II level, while 4 digits occurred within Ishikawa zone I level, 3 digits within Ishikawa zone II level, 7 digits within Ishikawa zone III level, and 1 digit within Ishikawa zone IV level. The replanted digits all survived (100%) without any indications of arterial insufficiency or venous congestion. The follow-up procedures were conducted on all 12 patients, with an average duration of 9.6 months (range, 6 to 18 months). The fracture successfully underwent healing at 9.2 weeks (range, 8 to 13 weeks). The mean VAS score was 1.75 points (range 0 to 4 points), the mean two-point discrimination test result was 5.72 mm (range 4.0 to 7.0 mm), and the mean DASH score was 9.78 points (range 3.33 to 22.5 points). All patients demonstrated cold tolerance and successfully resumed their pre-injury occupational activities. The nail deformity was observed in one digit following replantation within Tamai zone I, and in three digits following replantation within Tamai zone II; moreover, eight digits exhibited varying degrees of pulp atrophy. All patients expressed satisfaction with both functional and aesthetic outcomes.

CONCLUSION

The successful replantation of digit-tip amputation caused by crush injury can be achieved through the application of supermicrosurgery technique, resulting in improved functional and aesthetic outcomes. Digit-tip replantation is a favorable and meaningful procedure with high patient satisfaction.

Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention

OBJECTIVE

We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS).

METHODS

This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis.

RESULTS

A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively.

CONCLUSIONS

Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.

Use of supermicrosurgery in craniofacial and head and neck soft tissue reconstruction: a systematic review of the literature and meta-analysis

Supermicrosurgery is an evolving approach in the reconstruction of head and neck (HN) and craniofacial (CF) defects. This systematic review aims to evaluate the use of supermicrosurgery for arterial or combined arterial and venous anastomoses in the reconstruction of HN and CF soft tissue defects, and the associated success, total complication, and reoperation rates. A literature search was conducted on PubMed, Dynamed, DARE, EMBASE, Cochrane, and British Medical Journal (BMJ) electronic databases (PROSPERO ID: CRD42023476825). Nine studies fulfilled the inclusion criteria with 35 patients who underwent soft tissue reconstructive procedures using supermicrosurgery. Twenty-one flaps were performed on 20 patients (57.1%) with the remaining 15 patients (42.9%) undergoing supermicrosurgical replantation. The most common pathology requiring reconstruction was HN trauma (n = 16, 45.7%) followed by malignancy (n = 15, 42.9%). The pooled success rate for supermicrosurgery was 98% (95% CI 90 to 100, p = 1.00; I2 = 0%). The cumulative complication rate across all the studies was 46% (95% CI 13 to 80, p < 0.01; I2 = 0%), and the pooled rate of reoperation was 1% (95% CI 0 to 8, p = 0.23; I2 = 24%). The use of supermicrosurgery for HN and CF soft tissue reconstruction has an overall success rate of 98%, which is commensurate with traditional microsurgery for HN reconstruction. Complication and reoperation rates are comparable to previous literature. This study confirms the feasibility of supermicrosurgery as a safe and reliable reconstructive option for HN and CF defects.

Intravascular flipping technique for end-to-side microvascular anastomosis

Recent advances in minimally invasive perforator flaps, such as the superficial circumflex iliac artery (SCIP) flap, have increased the demand for anastomosing vessels with diameters less than 0.8 mm. However, discrepancies in size can occur, underscoring the significance of end-to-side anastomosis. Nevertheless, the conventional interrupted end-to-side suturing technique with vessel turnover presents challenges in situations with a limited operative field, short vascular pedicle, and tiny vessels. Therefore, we developed an intravascular flipping technique for end-to-side microvascular anastomosis with an inside technique or rotation-outside technique. The study involved 20 rats and with 15 arteries in 10 rats undergoing the flipping technique with inside or outside rotation. Both the inside and rotation-outside techniques exhibited a 100% immediate patency rate in the rats; however, after 1 week, this decreased to 80% and 86%, respectively. The SCIP flap and replantation procedures were successfully performed. The flipping technique offers several advantages, including ease of vessel manipulation using nylon threads and vascular clips, improved vessel visualisation, and spontaneous widening of the vessel lumen.

Overlapping lockup lymphaticovenous anastomosis: A useful addition to supermicrosurgery

BACKGROUND

Lymphaticovenular anastomosis (LVA) is a minimally invasive surgical procedure used to treat lymphedema. This surgical procedure connects the superficial lymphatic vessels to nearby veins to establish lymphatic-venous pathways. One of the most common challenges encountered by lymphatic surgeons when performing LVA is a mismatch in the sizes of the veins and lymphatic vessels, with the effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of an overlapping lockup anastomosis (OLA) LVA technique to address these problems.

METHODS

In this study, we present a novel OLA technique for LVA that addresses the challenges with conventional techniques. The OLA technique was used in 10 lymphedema patients between September 2022 and March 2023 to compare OLA and end-to-end anastomosis. The time required for anastomosis, method of anastomosis, patency rates, and lymphedema volume were evaluated in this study.

RESULTS

Of 123 LVAs, 44 were performed using the OLA technique in 10 patients, with indocyanine green lymphangiography revealing unobstructed drainage. A single case of slight fluid leakage occurred, which was resolved by reinforcing the sutures. The average anastomosis time for OLA and the end-to-end technique was 5.55 minutes and 12.1 minutes, respectively. The wounds of the patients healed without infection, and the subjective limb circumference decreased.

CONCLUSIONS

The OLA technique could serve as a valuable addition to the current LVA technique, especially for cases with a mismatch in the sizes of the lymphatic vessels and veins. This technique has the potential to promote the broader application of LVA in the treatment and prevention of lymphedema.

Dual intravascular stent flipping technique for microvascular anastomosis

The anastomosis of vessels <0.5 mm in diameter is challenging. We developed a supermicrosurgical anastomosis technique, the dual intravascular stent flipping technique with a double or single clip (dual flipping technique, double-clip technique, and single-clip technique). In the dual flipping technique, we used a 7-0 nylon intravascular stent and clipped the vessel along with the nylon. The double-clip technique was performed in 10 rats with 20 saphenous and 15 superficial inferior epigastric arteries. Immediate and 1-week patency rates were assessed. Subsequently, we examined ten epigastric arteries in five rats with the single-clip technique. The clinical application was performed in six cases involving finger/fingertip amputations, two cases involving radial artery superficial palmar branch flap, and one case involving superficial circumflex iliac artery perforator flap. Using the double-clip technique, the immediate patency rate was 90% and 93% in the saphenous and superficial epigastric arteries, respectively, whereas the 1-week patency rate was 81%. With the single-clip technique, the immediate patency rate was 100%. The replantation and flaps were successful. The advantages of the dual flipping technique included easy insertion, rare slipping-out possibility, and spontaneous vessel dilation by the flipped nylon. Additionally, the posterior vessel wall could be sutured more easily than could the anterior wall. By using the elasticity of the thread to invert the blood vessel, the posterior wall can be sutured without the double clip. When forceps tip insertion into the lumen is difficult, the dual flipping technique enables a relatively easy anastomosis if the 7-0 nylon is inserted into the vessel lumen.

Supermicrosurgery: past, present and future

Supermicrosurgery was popularised in 1997 and is defined as a technique of microvascular anastomosis for single nerve fascicles and vessels 0.3-0.8 mm in diameter. It requires the use of powerful microscopes, ultradelicate microsurgical instruments and specialist dyes. The development of supermicrosurgery has vastly improved the ability of microsurgeons to create true perforator flaps with minimal donor site morbidity for reconstructive surgery and improved the precision of additional microsurgical techniques. This review outlines the origins and history of supermicrosurgery, its current applications in reconstructive surgery (including fingertip reconstructions, true perforator flap surgery, nerve flaps and lymphoedema surgery), supermicrosurgery training and future directions for the field.

Successful replantation of amputated facial tissues by supermicrosurgery

BACKGROUND

Although replantation of amputated facial segments remains challenging in reconstructive surgery, it offers excellent aesthetic and functional outcomes.

METHODS

From May 2004 to October 2019, 12 patients underwent replantation of amputated facial tissues by supermicrosurgery. The case details, such as the rationale for replantation, the operation method, and postoperative therapy, are described. Four cases are discussed to demonstrate the replantation of different facial parts.

RESULTS

Facial tissue replantation was successful in all 12 patients without secondary surgery. The cases included the nose (1 patient), ears (8 patients), lips (2 patients), and one of the soft tissue segments surrounding the lower jaw. Venous congestion occurred in three patients who received a solitary arterial repair and were treated with bloodletting. All patients expressed satisfaction with the cosmetic and functional results at the final follow-up.

CONCLUSIONS

Supermicrosurgical facial tissue replantation is a promising and effective procedure for providing patients with the best aesthetic and functional outcomes.

Day microsurgery: Further application of free flap transfer as an ambulatory surgery

BACKGROUND

Free flap transfer (FFT) is essential in soft tissue reconstruction and can be done under local anesthesia. However, there is no study evaluating the feasibility of FFT without hospitalization. This study evaluated the feasibility of day microsurgery-FFT as a day surgery without hospitalization.

METHODS

Patients who underwent day microsurgery were included. The FFT was performed under local infiltration and/or block anesthesia without sedation by a surgeon with enough experience in supermicrosurgery. We focused on minimal dissection and secure hemostasis to prevent possible complications. Patient characteristics, operative findings, and postoperative course were evaluated.

RESULTS

Seventeen patients with a mean age of 40.4 years were included. All defects were of the upper extremity and due to trauma. Utilized anesthesia included local infiltration in 11 sites, digital block in 10 sites, wrist block in 12 sites, and elbow block in 4 sites. Used flap included superficial circumflex iliac artery perforator flap in 8 (47.1%) cases and short-pedicle partial toe flaps in 9 (52.9%) cases. The mean diameters of the anastomosed artery/vein were 0.88/1.29 mm, and the mean operation time was 68.9 min. All transferred flaps survived without total or partial necrosis. The postoperative course was uneventful except for 1 (5.9%) case with minor wound dehiscence.

CONCLUSIONS

FFT could safely be performed without hospitalization in selected cases of an upper extremity defect. Supermicrosurgery and careful patient selection play an important role in safe day microsurgery.

Impact of retrograde anastomosis during supermicrosurgical lymphaticovenous anastomosis for cancer-related lower limb lymphedema: A retrospective cohort propensity-score-matched outcome analysis

BACKGROUND

In addition to antegrade anastomosis, retrograde anastomosis has been thought to offer further improvements after lymphaticovenous anastomosis (LVA) by bypassing the retrograde lymphatic flow. However, this concept has yet to be validated. The aim of this study was to determine the impacts on outcomes of performing both retrograde and antegrade anastomosis, as compared to antegrade-only anastomosis for treating lower limb lymphedema.

STUDY DESIGN

This was a retrospective cohort propensity score-matched study. Eighty-seven patients with gynecologic cancer-related lower limb lymphedema were enrolled, including 58 patients who had received both antegrade and retrograde anastomoses (Group I) and 29 patients who had received antegrade-only anastomoses (Group II) as the control group. LVA was the primary treatment. Patients who had previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, and functional parameters including the ratio of indocyanine green-enhanced and flow-positive lymphatic vessels were recorded. Magnetic resonance volumetry was used for outcome assessments. The primary endpoint was the volume change at 6 months after LVA.

RESULTS

After matching, a total of 26 patients have remained in each group. All parameters were matched except that Group I still had significantly more median LVA performed compared to Group II (8 [IQR: 5.3-10.0] vs. 5.5 [4.3-6.0], p = 0.001, respectively). Group II showed more post-LVA improvements at six-month and one-year follow-up compared to Group I but without statistically significant differences.

CONCLUSION

The use of supplementary retrograde anastomoses is discouraged since it may lead to inferior post-LVA outcome compared to antegrade-only anastomoses.

Expanding indication of free hypothenar flap transfer: Sequential pedicled ulnar palm flap transfer to a relatively large hypothenar flap donor site

BACKGROUND

Free hypothenar flap (HTF) transfer allows sensible soft tissue reconstruction of the fingertip. However, HTF is basically indicated for a relatively small soft tissue defect, as width of an HTF is limited up to approximately 20 mm to allow primary donor site closure. Combined with sequential local flap to an HTF donor site, a larger HTF can be used without the contracture risk. The aim of this study was to evaluate feasibility of free HTF transfer and sequential ulnar palm flap (UPF) transfer (HTF-UPF) for relatively large fingertip reconstructions.

METHODS

Medical charts of patients who underwent HTF-UPF for fingertip reconstruction were reviewed. An HTF was designed transversely proximal to the proximal palmar crease, and a slightly smaller hemi-spindle-shaped UPF was designed longitudinally on the mid-lateral aspect of the ulnar palm; the UPF was used to close the HTF donor site. Patient and flap characteristics, intra-operative findings, and postoperative results were evaluated.

RESULTS

Twelve patients with average age of 42.7 years were included. HTF-UPF procedure was performed on 12 fingers. HTF's length/width ranged from 45/20 to 70/40 mm (average, 52.5/32.1 mm). UPF's length/width ranged from 40/20 to 55/30 mm (average, 46.7/24.2 mm). Time for sequential UPF transfer ranged from 3 to 9 min (average, 5.1 min). All HTFs and UPFs survived without flap necrosis or scar contracture. Postoperative sensation was comparable with the contralateral fingertip.

CONCLUSIONS

HTF-UPF procedure allows relatively large fingertip reconstruction with a minimum risk of HTF donor site contracture.

Mechanism and design of a novel 8K ultra-high-definition video microscope for microsurgery

The practical application of microscopes using 8K ultra-high definition (UHD) technology is progressing. However, due to insufficiencies in factors such as luminous intensity and stereopsis, it has not been possible to achieve sufficient image quality for close observation of submillimeter order microlymphatic anastomosis using a combination of 8K-UHD cameras with a rigid endoscope. We have improved the quality of microsurgery by the introduction of a new heads up 8K-UHD surgical system. Herein, we show the mechanisms of this next-generation technology that makes optical improvements to the electronic image input data, resolving the initial drawback.

We have developed a new 8K-UHD digital microscope system with digital zooming to enable maximum 300X magnification of the surgical field. This system has specific lighting settings for shadows dropped in surgical field to expand the three-dimensional effect while still being a monocular camera. The original mechanism and design enable the increase of the depth of field with optimal angles between the imaging direction and approaching direction towards the surgical field.

Assessment during a pre-clinical trial using rats demonstrated that it is possible to perform microlymphatic anastomosis in a heads-up position with a 70-inch 8K-UHD monitor and the 8K-UHD monocular camera system.

Performing supermicrosurgery is difficult with conventional surgical microscopes. Our results illustrate the application of this new 8K-UHD microscope system to this new field.

Lymph Node to Vein Anastomosis (LNVA) for lower extremity lymphedema

The microsurgical options for lower limb lymphedema is a challenge. In search to improve the overall result, we hypothesized it would be beneficial to add the functioning lymph nodes to vein anastomosis (LNVA) in addition to lymphovenous anastomosis (LVA). This is a retrospective study of 160 unilateral stage II & III lower extremity lymphedema comparing the outcome between the LNVA + LVA group and the LVA only group from May 2013 to June 2018. MRI was used to identify the functioning lymph nodes. Patient outcome, including lower extremity circumference, body weight, bio impedance test, and other data were analyzed to evaluate whether lymph nodes to vein anastomosis (LNVA) improved outcome. The LNVA + LVA group showed significantly better results for circumference reduction rate, body weight reduction rate, and extracellular fluid reduction rate of the affected limb as compared to the LVA only group for both stage II and III lymphedema. The MRI imaging revealed that 9 cases had no identifiable lymph nodes of the affected limb and 54 cases with a nonfunctioning lymph node upon exploration despite positive imaging. Correlation showed the lymph node size needed to be at least 8 mm in the MRI to be functional. The LNVA + LVA approach for lymphedema has the benefit of better reduction as compared to LVA alone in the lower limb as well as the suprapubic region. Preoperative MRI will help to identify the functioning lymph node by increasing the overall probability of positive outcome.

Supermicrosurgery in Lower Extremity Reconstruction

Supermicrosurgery is defined as microsurgery working on vessels less than 0.8 mm, allowing applications in smaller-dimension microsurgery, such as lymphedema, minimal invasive reconstruction, small parts replantation, and application of perforator as recipient. To accommodate this technique, developments and use of finer instruments, smaller sutures, new diagnostic tools, and higher-magnification microscopes have been made. Although supermicrosurgery has evolved naturally from microsurgery, it has developed into a unique field based on different thinking and tools to solve problems that once were difficult to solve.

Free-Style Free Perforator Flaps in Lower Extremity Reconstruction

Improved knowledge of vascular anatomy has enabled surgeons to preoperatively identify perforators and design free-style flaps based on that perforator. Options for choosing the optimal donor site tissues are increased with the free-style technique. This reduces donor site morbidity while providing the same reconstructive success as traditional free skin flaps. The free-style technique allows the surgeon to successfully complete reconstruction when aberrant anatomy is encountered. With the necessary skills in perforator flap dissection and supermicrosurgery, the armamentarium of the reconstructive microsurgeon has been expanded with the introduction of free-style perforator free flaps.

Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience

BACKGROUND

Resorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body.

PATIENTS AND METHODS

Between April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps).

RESULTS

Of all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%.

CONCLUSIONS

Free flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.

Determining factors in relation to lymphovascular characteristics and anastomotic configuration in supermicrosurgical lymphaticovenous anastomosis - A retrospective cohort study

INTRODUCTION

Supermicrosurgical lymphaticovenous anastomosis (LVA) can be performed in different configuration such as end-to-end (LVEEA), end-to-side (LVESA), and side-to-end (LVSEA). Each configuration has its own advantages and disadvantages. However, it has remained ambiguous as to which anastomotic o configuration to choose. The aim of this study is to analyze and compare the relative sizes of lymphatic vessel (LV) and recipient vein (RV), in attempts to provide the basis for proper selections of the anastomotic configuration.

METHODS

From March 2016 to October 2018, 100 lymphedema patients with 103 lymphedematous lower limbs (stage I-III) were included. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings, including the number and size of the LV/RV, the size discrepancies, and the numbers of LVA performed were recorded. The severity of LVs were classified based on the lymphosclerosis classification (s0, s1, s2, and s3). One-way ANOVA test and post hoc analysis with Bonferroni's correction were performed for size discrepancy analysis.

RESULTS

A total 730 LVA were performed with 621 LVs and 468 RVs, averaging 7.1 LVA per limb. Of these, 367 (50.3%) were LVEEA, 333 (45.6%) were LVESA, and 30 (4.1%) were LVSEA. The average LV and RV size was 0.61 ± 0.35 mm and 0.87 ± 0.43 mm, respectively (p < 0.001). The average LV size in different configuration: LVEEA = LVESA < LVSEA (p < 0.001); The average RV size: LVEEA = LVSEA < LVESA (p < 0.001); The size discrepancy: LVESA > LVSEA > LVEEA (p < 0.001).The LVSEA group has more s1 lymphatic vessels as opposed to LVEEA and LVESA (p = 0.004).

CONCLUSION

The size and the comparative discrepancy between the LVs and RVs are the determining factors for proper anastomotic configuration selection during LVA. LVESA was more frequently performed when vessel size discrepancy was larger. The efficacy of each anastomotic configuration has yet to be determined.

Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.

Supermicrosurgery in fingertip defects-split tibial flap of the second toe to reconstruct multiple fingertip defects: A case report

BACKGROUND

Injuries to multiple fingertips pose a significant treatment dilemma. Numerous reconstructive options exist, all with the ultimate goal of restoring function and sensibility to the injured fingertips.

CASE SUMMARY

A 24-year-old male suffered injury to multiple fingertips of the right hand, resulting in exposed distal phalanges of the middle, ring, and small fingers. The amputated distal stumps were not possible for replantation. Free flap coverage was selected in order to achieve better functional outcome. The fingertip defects were covered by performing a right second toe split tibial flap using local anesthesia at the harvest site and brachial plexus nerve block for the right upper extremity. At 6-month follow-up, all three of the reconstructed fingertips had some preserved nail growth, Semmes-Weinstein Monofilaments testing was equal to the contralateral side and the Static Two-Point Discrimination were comparable to the contralateral side.

CONCLUSION

This report provides a novel reconstructive option for the management of multiple fingertip injuries and demonstrates the utility of supermicrosurgery in management of these injuries.

Near-infrared fluorescence imaging for the prevention and management of breast cancer-related lymphedema: A systematic review

Sentinel lymph node identification by near infrared (NIR) fluorescence with indocyanine green (ICG) is recognized in the literature as a useful technique. NIR fluorescence technology could become key in the prevention and management of lymphedema after axillary dissection for breast cancer. Here, we conducted a systematic review focusing on ICG imaging to improve lymphedema prevention and treatment after axillary surgery. A systematic literature review was performed using MEDLINE and Embase to identify articles focused on ICG imaging for breast-cancer-related lymphedema (BCRL). Qualitative analysis was performed to summarize the characteristics of reported ICG procedures. In situ tissue identification and functionality assessment based on fluorescence signal were evaluated. Clinical outcomes were appraised when reported. Studies relating to axillary reverse mapping, lymphography and upper limb supermicrosurgery combined with ICG imaging were identified. We included a total of 33 relevant articles with a total of 2016 patients enrolled. ICG imaging for axillary reverse mapping was safe for all 951 included patients, with identification of arm nodes in 80%-88% of patients with axillary lymph nodes dissection. However, the papers discuss the oncologic safety of the approach and how - regardless of the contrast agent - concerns limit its adoption. ICG lymphography is openly supported in BCRL management, with 1065 patients undergoing this procedure in 26 articles. The technique is reported for lymphedema diagnosis, with high sensitivity and specificity, staging, intraoperative mapping and patency control in lymphaticovenular anastomosis. The substantial advantages/disadvantages of ICG imaging procedures are finally described.

Recent Topics on Fingertip Replantations Under Digital Block

The authors describe 3 cases with successful fingertip replantations using supermicrosurgical arteriole (terminal branch of digital artery) anastomoses, arteriole graft obtained from the same fingertip defect, reverse arteriole flow to subdermal venule, and delayed venular drainage for venous congestion. Among these 16 consecutive distal phalangeal replantations, 7 fingers showed postoperative venous congestion (43.8% of the total fingers) and 5 were reoperated on with delayed venous drainage under digital block. All the reoperated fingers were successfully drained by additional single or double venous drainage with a vein graft (100% success rate). As a result, 13 fingers survived (81.3% success rate).

Feasibility and reliability of supermicrosurgical vasa recta anastomosis for double-pedicled free jejunum transfer

Background

Although free jejunal transfer is an established and reliable procedure for reconstruction after total pharyngolaryngectomy (TPL), vascular thrombosis remains a surgical challenge. To reduce the risk, a double-pedicled free jejunal flap transfer has been attempted using a root jejunal artery and an arcade artery, although several drawbacks exist. The vasa recta are terminal straight vessels that arborize from an arcade artery without branching. We present a novel double-pedicled free jejunum transfer using vasa recta anastomosis.

Methods

Between 2011 and 2015, we performed 14 double-pedicled free jejunal flap transfers for reconstruction after TPL. Vasa recta were used for second arterial anastomosis in 5 out of 14 patients. Others include a root artery in three patients and an arcade artery in six patients. Indocyanine green (ICG) angiography was performed to confirm the patency and perfusion of the entire flap by the second artery alone.

Results

The flaps survived completely in all cases. The vasa recta (average diameter; 0.8 mm) were anastomosed to the superior thyroid artery and transverse cervical artery in four and one cases, respectively. Supramicrosurgical end-to-side anastomosis was performed in two cases. ICG angiography showed sufficient perfusion of the entire flap with the second artery alone in all cases.

Conclusion

As vasa recta were confirmed as being capable of perfusing the entire flap up to 25 cm, the double-pedicle method using vasa recta might be an option to reduce the risk of flap necrosis, particularly in high-risk patients.

Onco-reconstructive supermicrosurgery

Supermicrosurgery is sophisticated microsurgical technique, which allows dissection and anastomosis of blood/lymphatic vessels and nerves with external diameter of 0.5 mm or smaller. With increasing attention to quality of life of cancer survivors, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques is warranted. Unlike conventional free flap reconstruction, supermicrosurgical free flaps can be elevated from anywhere using innominate vessels with diameter of 0.1 mm or larger, allowing patient-oriented least invasive reconstruction. Since lymphatic vessels can be anastomosed, lymphatic reconstruction is possible with supermicrosurgery, which plays an important role in management of cancer-related lymphedema. Supermicrosurgeons can harvest vascularized tissues such as skin, fat, fascia, tendon, ligament, bone, muscle, and nerve separately, and reconstruct complicated defects with three-dimensionally-inset multi-component tissue transfer.

Evolution of an evidence-based supermicrosurgery simulation training curriculum: A systematic review

BACKGROUND

Supermicrosurgery (SM) involves operating on vessels with calibers from 0.3-0.8 mm. SM requires skills beyond those of conventional microsurgery. Current microsurgery courses do not prepare a junior surgeon for such a challenge. Several models have been developed to assist in the early learning curve, but their true purpose, benefit, and validation have not been addressed. This systematic literature review summarizes the existing SM simulation models, and their likely impact on microsurgery training for small-caliber vessel-based procedures is assessed.

METHODS

An electronic literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. From the literature search, 90 potential articles from MEDLINE and 300 articles from other databases were identified and screened. Twenty-five studies were screened against the inclusion criteria by two independent reviewers for a final critical analysis.

RESULTS

Thirty-six articles were included in the reviewing process, and 15 SM simulation training models were identified. The simulation models were classified as nonbiological or biological and as ex vivo or in vivo. None of these models demonstrated validity. However, critical analysis of the full-text articles established the clinical correlation of each model along with the specific skill demonstrated. A novel ladder-based curriculum was established. Further, an expert's questionnaire generated a Likert scale and the clinical impact of each SM simulation training model.

CONCLUSION

This is the first review to highlight the clinical relevance of SM models and the need for validation. Currently, a variety of training models in SM appear to enable the acquisition of specific skills, and the clinical impact of a selection is recognized in a proposed SM simulation training curriculum.

Innervated dorsoradial perforator free flap: A reliable supermicrosurgery fingertip reconstruction technique

INTRODUCTION

This study demonstrates the use of a modified free innervated DRAP flap utilizing the supermicrosurgery technique for fingertip reconstruction.

MATERIALS AND METHODS

From January 2010 to February 2014, 20 cases of fingertip reconstruction were performed using a short pedicle mini innervated transverse DRAP flap. The patients demographics, the mechanism of injury, the defect size and anatomical location, the source of pedicle vessels, the recipient vessels, the nerve branch used for innervation, the follow-up and sensation outcomes are reported. Three cases are presented demonstrating different anatomical fingertip injury reconstructions.

RESULTS

20 consecutive traumatic fingertip injuries (M:F-14:6) were reconstructed with a free DRAP flap from the same hand. 6 index, 6 middle, 5 ring and 3 little finger defects were included in this study. All procedures were performed under regional anaesthesia and sedation. There were no intra- or post-operative complications. The average operative time was 105 (85-120) minutes. Each flap size was matching the size of the defects. All donor sites achieved primary closure and good cosmesis. The average follow-up was 12.8 (6-28) months. Follow-up demonstrated a static two-point discrimination of the flaps with an average distance of 5.5 (4-7) mm.

CONCLUSION

The innervated DRAP flap has proven to be an easy, reliable and effective sensate fingertip reconstruction option, utilizing the supermicrosurgery technique.

LEVEL OF EVIDENCE

Level IV, retrospective series.

Supermicrosurgery-assisted venous supercharging of a reverse-flow angular artery perforator flap for nasal reconstruction

The centre ground in the world of flaps have over time, gradually shifted from tubed pedicled, random-pattern, axial-pattern, pedicled, free and currently, to free-styled flaps. These concepts are broadly based on the angiosome-perforasome concept. In this case report, we illustrate how the concept of venosome capture can be transposed onto reverse-flow flaps with the aid of venous supercharging. Moreover, if this is seen from the free-styled flap perspective, it requires supermicrosurgical expertise. This case report hence, serves as a fusion of all the above concepts.

Quadruple-component superficial circumflex iliac artery perforator (SCIP) flap: A chimeric SCIP flap for complex ankle reconstruction of an exposed artificial joint after total ankle arthroplasty

Total ankle arthroplasty (TAA) is becoming popular in patients with rheumatoid arthritis (RA)-associated ankle joint degeneration. However, ankle wound complications can occur after TAA, which sometimes requires challenging reconstruction due to anatomical complexity of the ankle. Superficial circumflex iliac artery (SCIA) perforator (SCIP) flap has been reported to be useful for various reconstructions, but no case has been reported regarding a chimeric SCIP flap for complex ankle reconstruction. We report a case of complex ankle defect successfully reconstructed with a free quadruple-component chimeric SCIP flap. A 73-year-old female patient with RA underwent TAA, and suffered from an extensive ankle soft tissue defect (13 × 5 cm) with exposure of the implanted artificial joint and the extensor tendons. A chimeric SCIP flap was raised based on the deep branch and the superficial branch of the SCIA, which included chimeric portions of the sartorius muscle, the deep fascia, the inguinal lymph node (ILN), and the skin/fat. The flap was transferred to the recipient ankle. The sartorius muscle was used to cover the artificial joint, the deep fascia to reconstruct the extensor retinaculum, the ILN to prevent postoperative lymphedema, and the adiposal tissue to put around the extensor tendons for prevention of postoperative adhesion. Postoperatively, the patient could walk by herself without persistent leg edema or bowstringing of the extensor tendons, and was satisfied with the concealable donor scar. Although further studies are required to confirm efficacy, multicomponent chimeric SCIP has a potential to be a useful option for complex defects of the ankle.

Preoperative color Doppler ultrasound assessment in planning of SCIP flaps

INTRODUCTION

Superficial circumflex iliac artery perforator (SCIP) flap is based on the perforator of superficial circumflex iliac artery (SCIA) system, and is a highly useful surgical tool with a wide variety of clinical applications. The SCIA system is associated with considerable anatomical variation, however, rendering transfer of a SCIP flap technically difficult.

PATIENTS AND METHODS

Using preoperative color Doppler ultrasound (US), we examined a total of 11 flaps of 11 patients who had undergone reconstruction with SCIP flap from April to August of 2014. The origin of SCIA from femoral artery and the bifurcation of its superficial branch and deep branch were easily identifiable in all patients. Perforator courses and their penetration points were marked to guide dissection.

RESULTS

Although one patient required secondary revision and skin grafting because of partial necrosis, there were no serious postoperative complications such as total necrosis or resulting absorption of the transferred adiposal flap. In all cases, findings from the preoperative color Doppler US were useful in delineating the dominant vessel within the groin lesion.

CONCLUSION

Using the technique described above, difficulties arising from the anatomical variation within the SCIA system are easily overcome, simplifying SCIP flap harvest. In addition to being relatively easy, the technique is also quick to administer and safe.

Supermicrosurgery and hyaluronic acid: experimental feasability study of a new method

INTRODUCTION

As a technique of anastomosis for vessels of less than 0.8mm in diameter, supermicrosurgery has aroused renewed interest on account of its potential clinical applications. The technical difficulty of surgery at such a small scale necessitates exploration of new methods likely to render the anastomoses accessible and reliable. The aim of this article is to present the results of an experimental study on the feasibility of anastomoses (arterial diameter ≤0.5mm), assisted by the injection of hyaluronic acid (HA).

MATERIALS AND METHODS

Ten end-to-end arterial anastomoses of the inferior epigastric artery (diameter ≤0.5mm) were performed in 5 rats. An injection of HA had previously been carried out in the vessel lumen and the sutures were made with 12-0 nylon. Immediate and 3-day permeability were controlled and anastomosis times were measured.

RESULTS

Average diameter of the arteries was 0.42 mm (range 0.29-0.48 mm). Mean anastomosis duration was 19.5 min (range 15-23 min). The average number of stitches was 6. Immediate patency was 100% with a success rate of 80% at 3 days.

CONCLUSIONS

The properties of HA seem to effectively facilitate anastomoses of arteries with a diameter ≤0.5mm. HA provides comfort and promotes safety in performance of exceedingly small-scale surgery. While the results appear promising, but further studies are needed in order to determine the potential toxicity of this method on tissues.

Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation

BACKGROUND

Lymphorrhea can occur after surgical intervention to the lymphatic system. Most cases with lymphorrhea can be treated conservatively, but some cases are refractory to conservative treatments and require further surgical treatments.

METHODS

Eight patients developed inguinal lymphorrhea after surgical intervention in the groin region. Navigation lymphatic supermicrosurgery (NLS) was performed for the treatment of iatrogenic lymphorrhea refractory to conservative treatments. Lymphatic vessels ruptured in a lymphorrhea lesion were identified under intraoperative indocyanine green (ICG) lymphography navigation and were anastomosed to a recipient vessel; an intact lymphatic vessel or a vein was selected as a recipient. Feasibility and efficacy of the method were evaluated.

RESULTS

Among eight inguinal lymphorrhea patients, four patients with refractory lymphorrhea underwent NLS under local anesthesia. In all cases, a lymphatic vessel that caused an intractable lymphorrhea was successfully anastomosed to a recipient vessel (to an intact lymphatic vessel in one case, and to a venule in three cases), and the lymphorrhea was completely cured without lymphorrhea recurrence or lymphedema development. Treatment duration in NLS was significantly shorter than that in conservative treatments (5.0 ± 2.4 vs. 30.0 ± 8.1 days, P = 0.006).

CONCLUSIONS

Intraoperative ICG lymphography helps a surgeon to find lymphatic vessels in and near a lymphorrhea lesion, which allows secure and easier treatment for an intractable lymphorrhea with preservation of lymph drainage function.

Supermicrosurgical free sensate intercostal artery perforator flap based on the lateral cutaneous branch for plantar reconstruction

The use of an intercostal artery perforator (ICAP) flap has recently become popular in reconstructive surgery. We have developed a novel free sensate ICAP flap based on the lateral cutaneous branch (LCB) and applied it to a case with a plantar defect. To the best of our knowledge, this case is the first to describe a free sensate ICAP flap based on the LCB. This method has several advantages: (1) a sensate flap is possible because the LCB neurovascular bundle is consistently available; (2) the long neurovascular pedicle can be harvested in the supine position without the risk of pneumothorax; (3) the donor-site morbidity is low; and (4) conversion or combination with a superficial circumflex iliac artery perforator (SCIP) or a superficial inferior epigastric artery (SIEA) flap is readily possible. We believe that this method represents a new option for soft-tissue reconstruction.

Microvascular anastomosis of submillimeter vessels-a training model in rats

The advent of supermicrosurgery, which allows the anastomosis and dissection of small-caliber vessels ranging from 0.5 to 0.8 mm in diameter, has led to the development of new reconstructive operations. Lymphaticovenous anastomosis, fingertip replantation and perforator flap surgery all require the supermicrosurgical techniques. In this paper, a rat model is described for the training of anastomosis of submillimeter vessels. Spraque-Dawley rats with the weight of 300 to 500 g were used as the training models. The gender, weight and size of the femoral vessels of 20 rats were recorded. The segment of the femoral vessel which was lying on the ventral muscle group of the hind limb and distal to the origin of the superficial inferior epigastric vessels was used for the practice of microvascular anastomosis. In this study, there were 13 male and 7 female rats. The mean weight of the 20 rats was 395.6 g. The mean diameters of the femoral artery and femoral vein were 0.54 mm and 0.56 mm respectively. The consistent size and anatomy of the femoral vessel make it a suitable training model for microvascular anastomosis of submillimeter vessels.

Microvascular Anastomosis of Vessels Less Than 0.5 mm in Diameter: A Supermicrosurgery Training Model in Lagos, Nigeria

The development of reconstructive microsurgery has now reached the supermicrosurgery stage. However the anastomosis of vessels under 0.5 mm is still out of the comfort zone of the many microsurgeons. To confirm the technical feasibility and the reliability of this technique We relate our own experience in this regard using the free superficial inferior epigastric flap of the rat as a model for supermicrosurgery training at the Microsurgery Laboratory of the Lagos University teaching hospital. 18 of the 20 free flaps transferred survived at 1 week. Two flaps necrosed and two flaps dehisced. We believe based on our work that the average microsurgeon can become comfortable working with these vessels.