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Vascularized lymph node transfer (VLNT) is an advanced surgical approach for secondary lymphedema (SLE) treatment, but tissue fibrosis around the lymph node flap (VLNF) inhibiting lymphangiogenesis is the biggest challenge undermining its therapeutic efficacy. This study explored the effects of periodic hyaluronidase (HLD) injection in reducing fibrosis and promoting lymphangiogenesis in 52 Sprague–Dawley rats with a VLNF over 13 weeks. The results demonstrated that HLD administration significantly enhanced swelling reduction, lymphatic drainage efficiency, and lymphatic vessel regeneration, with up to a 26% decrease in tissue fibrosis around the VLNF. These findings suggest that combining VLNT with periodic injections of HLD could substantially improve SLE treatment outcomes in clinical settings. It offers a promising direction for future therapeutic strategies and drug development aimed at increasing the efficacy of surgical treatment for SLE patients. [ABSTRACT FROM AUTHOR]

Background Lymph nodes may play a potential role in lymphedema surgery. Radiologic evaluation of nodes may reveal the status of pathologic conditions but with limited accuracy. This study is the first to evaluate the efficacy of ultrasound in detecting functioning nodes in lymphedema patients and presents a criterion for determining the functionality of the lymph nodes. Methods This retrospective study reviews 30 lower extremity lymphedema cases which were candidates for lymph node to vein anastomosis. Lymphoscintigraphy and magnetic resonant lymphangiography (MRL) imaging were compared with ultrasound features which were correlated to intraoperative indocyanine green (ICG) nodal uptake as an indication of functionality. Results Majority were International Society of Lymphology stage 2 late (50.0%) and stage 3 (26.7%). ICG positive uptake (functioning nodes) was noted in 22 (73.3%), while 8 patients (26.6%) had negative uptake (nonfunctioning). Ultrasound had significantly the highest specificity (100%) for identifying functional nodes followed by lymphoscintigraphy (55%) and MRL (36%; p = 0.002 , p < 0.001 , respectively). This was associated with 100% positive predictive value compared against lymphoscintigraphy (44%) and MRL (36%; p < 0.001 for both). The identified ultrasound imaging criteria for functioning lymph node were oval lymph node shape (Solbiati Index), morphology, vascularity pattern, and vascularity quantification. Conclusion The use of ultrasound in nodal evaluation was proven effective in different pathologic conditions and demonstrated the best prediction for functionality of the lymph node based on the new evaluation criteria. [ABSTRACT FROM AUTHOR]

Background This study aimed to quantify the blood flow of free flaps and compare the blood flow of small vessel (<0.8 mm) and larger vessel (>0.8 mm) anastomosed free flaps. Methods This retrospective study included patients treated successfully with a perforator free flap in the lower extremity between June 2015 and March 2017. A color duplex ultrasound system measured the flow volume through the pedicle by analyzing the mean flow peak velocity, flow volume, and flow volume per 100 g of the flap. Results A total of 69 patients were enrolled in this study. There was no statistical difference in peak velocity between the small vessel anastomosed free flap (25.2 ± 5.6) and larger vessel anastomosed free flap (26.5 ± 5.4). Flow volume (6.8 ± 4.2 vs. 6.3 ± 3.6) and flow volume/100 g (3.6 ± 3.9 vs. 6.2 ± 6.9) also did not show significant differences. Conclusion Small vessel (<0.8 mm) free flaps showed similar flow velocity and flow volume to larger vessel (>0.8 mm) anastomosed free flaps. Blood flow to the small vessel anastomosed free flap was sufficient despite its small vessel size. [ABSTRACT FROM AUTHOR]

The mammalian target of rapamycin (mTOR) inhibitors are used to prevent organ transplant rejection and are preferred over other immunosuppressants due to its low nephrotoxicity. However, mTOR inhibitors have been associated with various adverse effects including lymphedema. Although rare in incidence, previously known treatments for mTOR inhibitor-induced lymphedema were limited to discontinuation of related drugs and complex disruptive therapy with variable results. In this article, three patients who developed lymphedema in their lower limbs after using mTOR inhibitors, including two bilateral and one unilateral case, were treated with physiologic surgery methods such as lymphovenous anastomosis (LVA) and lymph node transfer. The efficacy of the treatment was evaluated. In the three cases described, cessation of the drug did not lead to any reduction in edema. The use of LVA and lymph node transfer resulted in early reductions in volume but failed to sustain over time. All patients underwent secondary nonphysiologic surgery such as liposuction resulting in sustained improvement. This series presents the first physiologic approach to mTOR inhibitor-induced lymphedema. Although further study is warranted, the physiologic surgical options may have limited success and nonphysiologic options may offer better sustainable results. [ABSTRACT FROM AUTHOR]

Lipedema is a progressive connective tissue disease with enlargement of adipose tissue, fibrosis, fluid collection, and dermal thickening. Herein, we present a case of lipedema associated with skin hypoperfusion and ulceration in which soft tissue debulking with liposuction improved patients' symptoms. A 39-year-old female presented with asymmetric progressive initially unilateral lower limb swelling with severe pain with subsequent skin ulceration. Conservative management failed to improve her condition. After excluding other causes and detailed radiologic investigation, lipedema was diagnosed with an associated impaired skin perfusion. Trial of local wound care and compression therapy failed to improve the condition. Subsequent soft tissue debulking with circumferential liposuction and ulcer debridement and immediate compression showed dramatic improvement of the symptoms and skin perfusion. The unique nature of this case sheds light on lipedema as a loose connective tissue disease. Inflammation and microangiopathies explain the associated pain with hypoperfusion and ulceration being quite atypical and in part might be related to the large buildups of matrix proteins and sodium contents leading to fragility in microvessels with frequent petechiae and hematoma and subsequent tissue ischemia. Conservative measures like compression therapy plays a significant role in disease course. Surgical debulking with liposuction was shown to be efficacious in reducing the soft tissue load with improvement in limb pain, edema, circumference, and skin perfusion that was seen in our patient. Lipedema is a frequently misdiagnosed condition with disabling features. Skin involvement in lipedema with potential hypoperfusion was shown and it requires further investigation. [ABSTRACT FROM AUTHOR]

Light‐emitting diode (LED) lights produce a variety of wavelengths that have demonstrable efficacy in therapeutic and aesthetic fields. However, a repetitive treatment regimen is required to produce treatment outcomes, which has created a need for portable LED devices. In this study, we aimed to develop a portable therapeutic LED device and investigate its healing effect on excisional wounds in a rat model. The 35 × 35 mm‐sized LED device was used on a total of 30 rats with full‐thickness wounds that were divided into two groups depending on radiation intensity (11.1 and 22.2 mW/cm2 group). LED irradiation was performed every 24 h for 30 min, over 14 days, in direct contact with the wound. Percentage wound closure was measured by photographic quantification and was assessed histologically using haematoxylin and eosin (H&E) and Masson's Trichrome staining, and immunohistochemistry for Vascular endothelial growth factor (VEGF) and CD31. Percentage wound closure was significantly higher in 22.2 mW/cm2 irradiated wounds than that in the control wounds on days 7 and 10. The area of collagen deposition was remarkably larger in 22.2 mW/cm2 irradiated wounds than that in the control, with more horizontally organized fibres. CD31 immunostaining confirmed a significant increase in the number of microvessels in 22.2 mW/cm2 irradiated wounds than that in the control wounds, although there was no difference in VEGF immunostaining. Our novel portable LED device accelerates wound healing in a rat model, raising the possibility that portable LED devices can combine convenience with accessibility to play an innovative role in wound dressing. [ABSTRACT FROM AUTHOR]

Introduction This research aims to validate the proficiency and accuracy of the robotic microsurgery platform using rat femoral vessel model. Materials and Methods Total of 256 rat femoral vessels were performed, half using robotic and the other by manual microanastomosis by 8 microsurgeons with less than 5 years of experience given 8 trials (rats) each. Vessel demographics, proficiency (duration of suture and Structured Assessment of Robotic Microsurgical Skills (SARMS)) and accuracy (patency and Scanning Electron Microscopic (SEM)) was analyzed between the two groups. Results Using the robot, an average of 4 trials was needed to reach a plateau in total anastomosis time and patency. Significant more time was required for each vessel anastomosis (34.33 versus 21.63 minutes on the 8th trial, p<0.001) one factor being higher number of sutures compared to the hand-sewn group (artery: 7.86±0.51 versus 5.86±0.67, p=0.035, vein: 12.63±0.49 versus 9.57±0.99, p=0.055). The SARMS scores became nonsignificant between the two group on the 4th trial. The SEM showed higher tendency of unevenly spaced sutures, infolding, tears in the vessel wall for the hand-sewn group. Conclusion Using the robot, similar patency, accuracy, and proficiency can be reached through fast but steep learning process within 4 trials (anastomosis of 8 vessels) as the hand-sewn group. The robotic anastomosis may take longer time, but this is due to the increased number of sutures reflecting higher precision and accuracy. Further insight of precision and accuracy was found through the SEM demonstrating the possibility of the robot to prevent unexpected and unwanted complications., Competing Interests: This research was funded in part by MMI. Symani robotic platform and necessary robotic instrumentation was provided by MMI as part of the research funding agreement between MMI and Asan Medical Center. The senior author Joon Pio Hong is a consultant for MMI., (Thieme. All rights reserved.)

Background:  As the number of extremity amputations continues to rise, so does the demand for prosthetics. Emphasizing the importance of a nerve interface that effectively amplifies and transmits physiological signals through peripheral nerve surgery is crucial for achieving intuitive control. The regenerative peripheral nerve interface (RPNI) is recognized for its potential to provide this technical support. Through animal experiment, we aimed to confirm the actual occurrence of signal amplification., Methods:  Rats were divided into three experimental groups: control, common peroneal nerve transection, and RPNI. Nerve surgeries were performed for each group, and electromyography (EMG) and nerve conduction studies (NCS) were conducted at the initial surgery, as well as at 2, 4, and 8 weeks postoperatively., Results:  All implemented RPNIs exhibited viability and displayed adequate vascularity with the proper color. Clear differences in latency and amplitude were observed before and after 8 weeks of surgery in all groups ( p  < 0.05). Notably, the RPNI group demonstrated a significantly increased amplitude compared with the control group after 8 weeks ( p  = 0.031). Latency increased in all groups 8 weeks after surgery. The RPNI group exhibited relatively clear signs of denervation with abnormal spontaneous activities (ASAs) during EMG., Conclusion:  This study is one of few preclinical studies that demonstrate the electrophysiological effects of RPNI and validate the neural signals. It serves as a foundational step for future research in human-machine interaction and nerve interfaces., Competing Interests: None declared., (Thieme. All rights reserved.)

Summary: Lymphatic vessel wall and lumen visualization during anastomosis is challenging. Different techniques with variable efficacy have been described. Double-opposing color contrast is created using 10% fluorescein sodium, which stains lymphatic fluid yellow, causing a clear contrast to the blue marker-painted lymphatic wall, improving intralumen visualization during the anastomosis process. In this retrospective study, the authors evaluated the success rate of performing anastomosis between the side of the lymphatic vessel and the end of the vein (S-to-E LVA) in 281 patients. The LVA assessment showed mean lymphatic diameter of 0.44 ± 0.09 mm and mean vein diameter of 0.57 ± 0.14 mm with S-to-E success rate of 100% confirmed by postanastomosis indocyanine green lymphography. No adverse events were encountered. Fluorescein sodium was not used in 2 patients because of positive skin allergy test results. This method has the advantages of not needing an additional device, allowing clear visualization, and not staining the surrounding structures. This approach using opposing color contrast between fluorescent yellow and blue marker improved vessel edge identification, which translated into higher visualization and patency with 100% success rate in S-to-E LVA performance., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: The functional and dilated lymphatic vessel and veins with minimal backflow and pressure are considered ideal for lymphaticovenous anastomosis (LVA). How to select the ideal vein remains to be determined. This study aimed to provide further insight into selecting the ideal vein., Methods: This is a retrospective study evaluating 166 limbs with lymphedema with a minimal follow-up period of 12 months. The surgical approach included side-to-end LVA, including 1 group with a non-Venturi LVA and another with a small branch draining into a major vein (Venturi LVA). Preoperative and 1, 3, 6, and 12 months postoperative limb volume, circumference, reduction volume, and ratio were evaluated., Results: The postoperative volume reduction was significant for both groups when compared with their respective preoperative volume. When compared between the 2 groups, the Venturi LVA had a significantly higher reduction volume and ratio at postoperative 1 month (240.82 ± 260.73 cm³ versus 364.27 ± 364.08 cm³, 6.13 ± 5.62% versus 8.77 ± 6.64%; P < 0.05) and 3 months (289.19 ± 291.42 cm³ versus 432.50 ± 395.04 cm³, 7.31 ± 6.39% versus 10.55 ± 6.88%; P < 0.05) However, the reduction volume and ratio was not significant by months 6 and 12., Conclusions: This study provides further insight into selecting the ideal vein for LVA. By using a small vein draining into the main vein, valves play a role in reducing backflow. Furthermore, the Venturi effect allows significantly enhanced drainage, especially in the initial period after surgery. The effect slowly plateaus after few months, ultimately having a similar outcome of reduction at 12 months., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Primary lymphedema is characterized by lymphatic dysplasia in which one variant is Milroy's disease. The association with congenital chylothorax is even rarer with poor outcome. This is the first report to utilize peripheral lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA) for the management of such condition., Methods: Retrospective chart review of patients with Milroy's disease with complication of chylothorax between 2019 till 2023 was performed. Clinical assessment and radiological investigations were reviewed., Results: Six patients with mean age of 12±3.9 years and disease duration of 10.5±2.8 years were reviewed. Three had ISL stage 3 while others had stage 2 late disease. All had bilateral lower extremity lymphedema and chylothorax with history of chest tube drainage. After LVA and LNVA, significant reduction in extremity volume was noted (p=0.028) along with near complete resolution of chylothorax was noted during the long-term follow-up (32 ±17.9 months)., Conclusion: Milroy's disease complicated with chylothorax remains to be challenging. This is the first report utilizing peripheral bypass (LVA and LNVA) which resulted in improvement of both lower extremity lymphedema and chylothorax. The utility of this approach represents a promising modality in the management of this devastating condition., Competing Interests: Financial Disclosure Statement: The authors have no external funding supported this work. The authors have no conflicts of interest to declare., (Copyright © 2024 by the American Society of Plastic Surgeons.)