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Background:  Upper extremity (UE) replantation and revascularization are challenging surgical procedures, with survival rates being 50 to 90%. Preoperative risk stratification is challenging yet crucial as patients with comorbid conditions face increased complications. This study assesses the predictive value of the modified 5-item frailty index (5-mFI) for postoperative complications in these procedures., Methods:  A retrospective study was done using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2021) for UE replantation/revascularization. The 5-mFI score assigned points for comorbidities including pulmonary disease, heart failure, diabetes, hypertension, and functional status (0-5 scale; 1 point to each). 5-mFI scores stratified patients into <2 (low-risk) or ≥2 (high-risk) categories., Results:  Of 2,305 patients, the mean age and body mass index (BMI) were 53.13 years and 28.53 kg/m 2 , respectively. The 5-mFI ≥2 cohort experienced higher rates of all-cause complications, systemic complications, unplanned readmissions, and return to the operating room on univariate analysis. There was no significant difference in wound complication rates. Multivariable logistic regression showed that a higher 5-mFI was significantly associated with increased risks of all-cause mild and severe systemic complications. Wound complications, length of stay over 30 days, unplanned readmission, and return to the operating room were higher in high-risk patients, however not statistically significant., Conclusion:  5-mFI is an effective tool for evaluating risk in UE replantation and revascularization, correlating high scores with significantly increased postoperative complications. High-risk patients with 5-mFI ≥2 also had more reoperations and readmissions. The use of 5-mFI in preoperative assessments can help personalize management, enhancing patient selection and care quality in these complex reconstructions., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL., Methods:  A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded., Results:  A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements., Conclusion:  PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies., Competing Interests: None declared., (Thieme. All rights reserved.)

Background:  The purpose of this study was to: (1) evaluate the mechanism of lymph drainage through a vascularized lymph node (VLN) flap, and (2) investigate if the number of VLNs impacts lymph transit time through the flap., Methods:  Twenty-seven axillary VLN flaps were elevated in 14 Sprague-Dawley rats and divided into three groups ( n  = 9 each) based on the number of lymph nodes present: group 1 (0-VLNs), group 2 (2-VLNs), and group 3 (4-VLNs). Indocyanine green ( n  = 8/group) and Alexa680-albumin ( n  = 1/group) were injected into the edge of flaps and the latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through VLNs., Results:  Fluorescence was detected in the axillary vein after 229s [47-476], 79s [15-289], and 56s [16-110] in group 1, 2, and 3, respectively ( p  < 0.01). There was a negative correlation between the number of VLNs in the flap and the latency period (r = -0.59; p  < 0.05). Median flap weights were comparable in group 1, 2, and 3 (258 mg [196-349], 294 mg [212-407], 315 mg [204-386], respectively; p  = 0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit through VLNs., Conclusion:  Lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism appears to be the diffusion of fluid into the venous system via intratissue lymphaticovenous connections created during flap elevation. Increasing the number of lymph nodes in the flap is associated with a more rapid transit of fluid., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)