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Objective: Although collateral lymphatic vessels are known to develop in patients with lymphedema, little is known about their significance. In this study, we investigated truncal collateral lymphatic drainage pathways in patients with lower limb lymphedema using indocyanine green (ICG) lymphography. Methods: The ICG fluorescence images and clinical characteristics of 80 consecutive patients (160 lower limbs) with secondary leg lymphedema who underwent ICG lymphography between September 2020 and September 2022 were retrospectively reviewed. Results: Seven patients were identified to have a truncal collateral lymphatic drainage pathway starting in the lateral abdomen and running in the direction of the ipsilateral axillary lymph nodes. These patients had particularly severe symptoms of lymphedema around the thigh or abdominal region or had genital lymphedema. Conclusions: A truncal collateral lymphatic drainage pathway may be associated with severe lower limb lymphedema, particularly if involving the genitals.

Background:. When dealing with a weak smile, nerve transfer is a viable strategy. We evaluated outcomes of masseteric nerve to facial nerve transfers and compared them with direct muscle neurotization (DMN). Methods:. In a retrospective cohort study of 20 patients (n = 20), we compared nerve transfer versus DMN over a 6-year period (2016–2021). Outcomes were measured using the validated Sunnybrook score, Ackerman Smile Index, and Terzis scores. Statistical analysis was performed using the Wilcoxon sign rank and Mann-Whitney U tests. Results:. Comparing pre- versus postoperative scores after nerve transfers, there was a significant improvement in median overall Sunnybrook score (24 versus 47, P = 0.043), lip elevation (1 versus 2, P = 0.046), open mouth smile (1 versus 3, P = 0.003), and Terzis scores (1 versus 3, P = 0.005), with no difference in resting symmetry (−15 versus −5; P = 0.496). Compared with DMN, there was no difference in median Terzis score improvement from preoperative to postoperative state (2 versus 1, P = 0.838), median smile improvement (2 versus 2, P = 0.838), resting symmetry (10 versus 5, P = 0.144) or overall Sunnybrook score (23 versus 21, P = 1.000). Lip elevation improvement was in favor of nerve transfers (1 versus 0, P = 0.047). Conclusions:. This is the first study evaluating nerve transfer neurotization of smile-mimetic muscles and comparing the outcomes with DMN, with masseteric nerve as donor. Nerve transfer leads to improved facial mimetic function, smile excursion and open mouth smiles, as does DMN, with improvement in lip elevation in favor of nerve transfer. Nerve transfer was preferred for more severe smile weakness.

The incidence of cystic lymphatic malformation (CL) in an extremity is very rare. CL can be a cause of lymphedema in a lower limb. The most effective treatment for CL is sclerotherapy or excision; however, these treatments have the potential to cause fibrosis and obliteration of ruptured lymphatic vessels, which impairs lymphatic drainage and increases the risk of lymphedema. Lymphaticovenular anastomosis (LVA) combined with sclerotherapy may be a minimally invasive treatment option for CL in a lower limb. In this report, we describe a patient with CL complicated by lymphedema in a lower extremity, who we treated using LVA and ethanol sclerotherapy with satisfactory results. The patient was a 60-year-old man with a CL measuring 16 cm in diameter in the thigh region above the knee with lower limb lymphedema. The percentage of excess volume of the affected lower leg was 24.7%, preoperatively. Combined treatment using LVA with sclerotherapy was performed under general anesthesia. At 2 years after surgery, the reduction of excess volume of affected lower leg between preoperative and postoperative was 85.4%. In our previous report, the same combination therapy was used to treat CL and prevent lymphedema; however, in the present case, it was used to treat CL and lymphedema at one stage. LVA combined with sclerotherapy is a complementary minimally invasive treatment for CL accompanied by lymphedema.

Background:. Supermicrosurgery has allowed the replantation/revascularization of the pulp, but how does this currently compare with more proximal digit replantation/revascularization? Methods:. In a retrospective case study over a 5-year period at our institute, a total of 21 patients (n = 21) had either finger or pulp replantation-revascularization posttrauma. All pulp replants had a single-vessel anastomosis viz., “artery-to-artery” or “artery-to-vein” only, with venous outflow dependent on the skin-shave technique, while more proximal replants had both arterial and venous anastomoses. Age, sex, ischemic time, handedness, smoker status, and injury-replant interval were compared between the two groups, with all procedures performed by a single surgeon. The outcome parameters studied were length of hospital stay, timeline for wound healing, viability, and functional outcomes. Results:. Our patients consisted of 18 men and three women, of which 14.3% were smokers and 85.7% were right-handed. There were 11 finger replantation/revascularizations (n = 11) versus 10 pulp replantation/revascularizations (n = 10). The average age of digit replantation/revascularization patients was 44.8 years compared with 26.4 years in pulp replantation/revascularization patients (Student t test, P = 0.04). Mean ischemia time in digital replants was 67 minutes versus 32.3 minutes in pulp replantation/revascularization (Student t test, P = 0.056). Digital replantation/revascularization was viable in 72% of cases versus a 90% viability in the pulp subcohort. Conclusions:. In our patient cohort, pulp replantation/revascularizations produced better postoperative viability. Where supermicrosurgery expertise is available, pulp replantation/revascularization should be considered a worthwhile option when compared with digital replantation/revascularization.

Lymphoceles result from either trauma to the lymphatic vessels or after vein graft harvest, which occurs in 10% to 16% of patients. When a lymphocele persists despite conservative treatment, patients can experience undue distress. We have reported the case of successful treatment using lymphatic venous anastomosis (LVA) of an intractable lymphocele that had been refractory to conservative treatment, including stretch bandaging, drainage, and local injection for 2 years after great saphenous vein harvest. The lymphocele resolved shortly after the LVA without any adverse effects. LVA can be a useful and minimally invasive alternative treatment of lymphocele after harvesting the great saphenous vein.

Summary:. Several treatment options, including sclerotherapy and surgical excision, are available for the management of cystic lymphangioma. Lymphaticovenular anastomosis (LVA) has recently garnered attention in the field of microsurgery as a minimally invasive surgical reconstruction strategy. Combined treatment using surgical excision and LVA for large or persistent cystic lymphatic malformations has been reported but can be very invasive. This case report describes use of a combination of LVA and sclerotherapy to treat cystic lymphatic malformations with satisfactory results. This combination could be a complementary minimally invasive treatment for extensive cystic lymphatic malformations. The patient was an 18-year-old woman with a cystic lymphangioma from the axilla to the subclavicular area beneath pectoralis major and pectoralis minor. The size was a diameter of 12 cm and a maximum depth of 8 cm. The cystic lymphangioma was managed by combined treatment of LVA and ethanol sclerotherapy. The patient had subsequent resolution of the lymphangioma without any symptoms of lymphedema or recurrence. LVA is thought to be a less invasive treatment option when the lymphatics flowing into a cyst are detectable or can be targeted. However, this is not always the case, especially if the cyst is large, persistent, or infected. Combination of LVA with sclerotherapy is a relatively less invasive method with closure of the dead space using sclerotherapy without further exacerbation or occurrence of lymphedema. Therefore, combined treatment using LVA with sclerotherapy can be a complementary minimally invasive treatment option for a large or persistent lymphocele.

We describe a dementia patient with comorbid recurrent cellulitis and lymphedema in the left lower limb who was treated successfully for recurrent cellulitis by lymphaticovenular anastomosis (LVA). The patient, an 83-year-old woman, suffered from recurrent cellulitis three times a year on average for 15 years. Compression therapy was impossible because of dementia. After LVA, there has been no recurrence of cellulitis for 2 years.It is difficult to administer decongestive lymphatic therapy in some patients, such as patients with dementia. LVA is a promising treatment for recurrent cellulitis in a dementia patient with lymphedema.

Background:. Facial transplants represent the current exemplar in the reconstruction of severely damaged faces, whereas conventional free flap reconstruction has its limitations in restoring both function and surface cover. Methods:. In a retrospective study over 6 years (2014–2020), 5 cases (n = 5) of vascularized nerve flaps (VNFs) were performed by our team. These involved three acute and two late reconstructions. The mean age was 41 years with a maximum of 6-year follow-up. To objectify the different permutations and combinations, we categorized composite, chimeric, and hybrid VNFs into types I, IIa-c, and III, each with a unique characteristic. Postoperative function was evaluated using the validated Sunnybrook and Terzis scores for facial nerve palsy; masticatory function was assessed using dental impression studies. Results:. There was a 100% flap survival rate, with no instances of flap necrosis and only one complication: hematoma at 24 hours postoperative. Sunnybrook and Terzis scores showed a statistically significant improvement postoperatively, indicating both improved repose and facial expressions (paired student t test, P < 0.05). Given that each VNF was specifically customized for a particular patient, each type of VNF in this cohort was unique, thereby illustrating each type succinctly. Conclusions:. VNFs are separate entities from standard free flaps, as they require extensive preoperative planning to allow the deconstructing of composite blocks of tissue into separate vascularized entities and amalgamating them into a new conglomerate. This allows VNFs to fill a niche area in facial reconstructive surgery between face transplants and conventional free tissue transfers, with enormous potential.

Background:. Propeller flaps have a higher-than-normal incidence of partial flap necrosis. Although venous supercharging has been shown to reduce this risk, its application is limited outside the scope of lower limb propeller flaps. In this article, we look at the ability of arborization capture and supermicrosurgery to allow propeller flaps to capture adjacent perforasomes and significantly improve flap survival. Methods:. In a retrospective case series across two institutions, the outcomes of two groups of patients who had propeller flaps were compared. Group A patients were those who had conventional free-styled propeller flaps (n = 25), whereas Group B (n = 19) patients had propeller flaps algorithmically selected for either (1) arborization capture or (2) venous supercharging, or both. Two-way ANOVA analysis was performed to evaluate inter-group differences. Results:. Conventional propeller flaps had a 64% complete survival rate (32% partial necrosis rate and a 4% total necrosis rate) compared with a 94% complete survival rate in modified propeller flaps. Of the 12 cases of arborization capture (perforator complex diameters of 1–2 mm), only one flap sustained partial flap loss, whereas all seven supercharged propeller flaps (selected for perforator diameter

Summary:. Rheumatoid lymphedema is a rare but severely disabling condition caused by reduced lymphatic drainage. Most treatment methods are conservative and may lead to the exacerbation of lymphedema. Lymphatic venous anastomosis (LVA) is an effective treatment for lymphedema after surgery involving the lymphatic system, such as lymph node dissection for cancer treatment. LVA has not been used to treat rheumatoid lymphedema. We present a case of rheumatoid lymphedema treated with surgical procedures, including LVA. Following LVA, objective and subjective symptom relief was noted, along with decreased swelling and pain in the affected area. The postoperative course was uneventful. LVA for the treatment of rheumatoid lymphedema may provide definitive clinical improvements.

When reconstructing a congenital floating thumb, we describe two children in whom preservation of all five digits is achieved through successful transfer of a thoracodorsal artery perforator (TAP) flap and vascularized scapula. Key words: Chimera flap, congenital anomaly, floating thumb, hand, thumb

Background:. Although patients with obesity-induced lymphedema can be treated by weight loss therapy, they find it difficult to lose the required amount of weight. The aims of this study were to clarify the characteristics of the lymphatic vessels in patients with obesity-induced lymphedema and to determine the feasibility and efficacy of lymphovenous anastomosis (LVA) in these patients. Methods:. Twenty-two patients (44 edematous lower limbs) with a body mass index (BMI) >35 kg/m2 (obese group) and 91 patients with lymphedema (141 edematous lower limbs) and BMI

Summary:. Although a large number of treatments have been developed for lymphedema, definitive management still remains a challenge for plastic surgery, because not all surgical techniques have a positive effect on every patient, and good results are difficult to reproduce. However, it is important to recognize the efforts that Professor Isao Koshima and his colleagues together with the Government of Japan are carrying out to spread information to the different countries on the newest surgical techniques available in current plastic surgery and to motivate young doctors in developing countries to create a microsurgery unit in their home country, providing them with the necessary knowledge and skills to deliver real solutions to complex problems that were previously unanswered. As a result of this program, the authors present the first case of secondary lymphedema successfully treated with lymphaticovenular anastomosis in Costa Rica, Central America.

Background:. Although supermicrosurgical anastomosis is a widely known reconstructive microsurgical technique, it is difficult to perform. To expand the clinical use of supermicrosurgery, we used hemi-intravascular stenting (hemi-IVaS), which is performed by inserting an intravascular stent into one side of the vessel. We conducted lymphaticovenular anastomosis, free perforator flap transfer, and fingertip replantation with supermicrosurgical anastomosis using hemi-IVaS technique and examined its usefulness. Methods:. Between January 2013 and February 2015, 11 anastomoses in 11 cases of lymphaticovenular anastomosis for lymphedema patients, 14 anastomoses in 7 cases of free perforator flap transfer with supermicrosurgical perforator-to-perforator anastomosis, and 9 anastomoses in 5 cases of fingertip replantation were performed using hemi-IVaS. Time required for anastomosis and complications were examined. Flap survival rate was also examined in free perforator flap transfer cases and fingertip replantation cases. Results:. In all cases, anastomoses were performed without complications such as inadvertent catching of the back wall of the vessel during the procedure or the need for reanastomoses. The average time required to complete the anastomosis was 16.4 ± 3.20 minutes using the hemi IVaS technique. All flaps survived in the supermicrosurgical perforator-to-perforator anastomosis as well as fingertip replantation cases. Conclusions:. Hemi-IVaS could be a useful alternative to conventional intravascular stenting techniques and is also effective for supermicrosurgical perforator-to-perforator anastomosis. Further studies are needed to improve the success rate and to explore its other possible utilizations in supermicrosurgery.