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Although satisfactory volume reduction in secondary unilateral lower limb lymphedema after lymphaticovenous anastomosis (LVA) in the affected limb has been well reported, alleviation of muscle edema and the impact of LVA on the contralateral limb have not been investigated.This retrospective cohort study enrolled patients who underwent supermicrosurgical LVA between November 2015 and January 2017. Pre- and post-LVA muscle edema were assessed using fractional anisotropy (FA) and apparent diffusion coefficient (ADC). The primary endpoint was changes in limb/subfascial volume assessed with magnetic resonance volumetry at least 6 months after LVA.Twenty-one patients were enrolled in this study. Significant percentage reductions in post-LVA muscle edema were found in the affected thigh (83.6% [interquartile range = range of Q1 to Q3; 29.8-137.1] [FA], 53.3% [27.0-78.4] [ADC]) as well as limb (21.7% [4.4-26.5]) and subfascial (18.7% [10.7-39.1]) volumes. Similar findings were noted in the affected lower leg: 71.8% [44.0-100.1] (FA), 59.1% [45.8-91.2] (ADC), 21.2% [6.8-38.2], and 28.2% [8.5-44.8], respectively (all p0.001). Significant alleviation of muscle edema was also evident in the contralateral limbs (thigh: 25.1% [20.4-57.5] [FA]; 10.7% [6.6-17.7] [ADC]; lower leg: 47.1% [35.0-62.8] [FA]; 14.6% [6.5-22.1] [ADC]; both p0.001), despite no statistically significant difference in limb and subfascial volumes.Our study found significant reductions in muscle edema and limb/subfascial volumes in the affected limb after LVA. Our findings regarding edema in the contralateral limb were consistent with possible lymphedema-associated systemic influence on the unaffected limb, which could be surgically relieved.

Despite an increased incidence of secondary lower limb lymphedema (LLL) and severity of comorbidities with age, the impact of age on the effectiveness of lymphaticovenous anastomosis (LVA) in the older patients remains unclear. Methods: This retrospective cohort study enrolled older patients (age > 65 years) with secondary unilateral LLL. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings including lymphatic vessel (LV) diameter, LV functionality (indocyanine green-enhanced and Flow positivity), and lymphosclerosis classification were recorded. Magnetic resonance volumetry was used for measuring preoperative and postoperative volume changes at 6 months and one year after LVA as primary and secondary endpoints. Results: Thirty-two patients (29 females/3 males) with a median age of 71.0 years [range, 68.0 to 76.3] were enrolled. The median duration of lymphedema was 6.4 [1.0 to 11.7] years. The median LV diameter was 0.7 [0.5 to 0.8] mm. The percentage of ICG-enhanced and Flow-positive LVs were 89.5% and 85.8%, respectively. The total percentage of suitable LVs (s0 and s1) for LVA based on lymphosclerosis classification was 75.9%. There were significant six-month and one-year post-LVA percentage volume reductions compared to pre-LVA volume (both p < 0.001). A significant reduction in cellulitis incidence was also noted after LVA (p < 0.001). No surgical or postoperative complications were found. Conclusion: Relief of secondary LLL was achievable through LVA in older patients who still possessed favorable LV characteristics, including larger LV diameters as well as a high proportion of functional LVs with a low grade of lymphosclerosis.

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.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.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).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.

Background Supermicrosurgical lymphaticovenous anastomosis (LVA) alleviates lymphedema by draining stagnant lymph from the lymphatic vessels into the venous system. Nevertheless, LVA is believed to be unsuitable for treating moderate-to-severe lymphedema presenting diffuse-pattern dermal backflow (DB). Dermal backflow is considered to be the sign of superficial lymphatic functional failure that renders LVA ineffective. Based on a current algorithm, a more invasive vascularized lymph node flap transfer is recommended instead of LVA. This retrospective study aimed to further investigate and possibly challenge this concept. Study Design One-hundred patients with unilateral lymphedematous lower limbs who underwent LVA were included. Patients were divided into Group I (10 patients with mild lymphedema) and Group II (90 patients with moderate-to-severe lymphedema). Demographic data and intraoperative findings were recorded. The post-LVA volume reductions by magnetic resonance volumetry were recorded and analyzed. Results Preoperatively, significant differences were found in BMI (20.6 vs 26.0 kg/m2, p = 0.004) and the volume gained in the lymphedematous limb (396.8 mL vs 1,056.8 mL, p = 0.005) between Groups I and II. Postoperatively, a significant median post-LVA volume reduction (-282.0 mL vs -763.5 mL, p = 0.022) was found in Group II. However, there were no differences in the percentages of post-LVA volume reduction (-43.8% vs -36.4%, p = 0.793) in Groups I and II. Conclusions The use of supermicrosurgical LVA is as effective at treating moderate-to-severe lymphedema as milder lymphedema. The indication for LVA should be broadened to include such cases.

The default setting of microscope-integrated near-infrared fluorescence (MINIRF) using indocyanine green for locating superficial lymphatic vessels during lymphaticovenous anastomosis was limited to less than or equal to 70 percent intensity. The authors investigated whether maximizing the MINIRF intensity setting could increase the number of deep lymphatic vessels being found, thereby increasing the total number of lymphatic vessels for lymphaticovenous anastomosis.This longitudinal cohort study enrolled 94 patients (86 female and eight male patients) with lower limb lymphedema. Superficial lymphatic vessels were identified with the MINIRF default setting, before maximal intensity was used for deep lymphatic vessel detection. Primary/secondary endpoints included the number of superficial and deep lymphatic vessels identified. No control was used. Demographic data, intraoperative findings [including superficial and deep (indocyanine green-enhanced and non-indocyanine green-enhanced) lymphatic vessels], and severity of lymphosclerosis were recorded. Data in three regions of the lower limb (i.e., foot/above ankle, below knee, and thigh) were compared.A total of 481 lymphatic vessels were identified, comprising 260 superficial and 221 deep lymphatic vessels. The median number of lymphatic vessels found per patient was five (interquartile range, four to six), and the median lymphatic vessel size was 0.63 mm (interquartile range, 0.5 to 0.8 mm). No difference was found in number (p = 0.360), size (p = 0.215), or severity of lymphosclerosis (p = 0.226) between the overall superficial and deep lymphatic vessels in the three lower limb regions.Deep lymphatic vessel detection can be aided by maximizing MINIRF intensity. These deep lymphatic vessels are comparable to superficial lymphatic vessels in number, size, and functionality, making them potentially valuable for lymphedema improvement.Diagnostic, II.

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

BACKGROUND Functional lymphatic vessels are essential for supermicrosurgical lymphaticovenous anastomosis. Theoretically, the larger the lymphatic vessel, the better the flow. However, large lymphatic vessels are not readily available. Since the introduction of lymphaticovenous anastomosis, no guidelines have been set as to how small a lymphatic vessel is still worthwhile for anastomosis. METHODS In this longitudinal cohort study, unilateral lower limb lymphedema patients who underwent lymphaticovenous anastomosis between March of 2016 and January of 2019 were included. Demographic data and intraoperative findings including the number and size of lymphatic vessels were recorded. The cutoff size was determined by receiver operating characteristic curve analysis, based on the functional properties of lymphatic vessels. Clinical correlation was made with post-lymphaticovenous anastomosis volume measured by magnetic resonance volumetry. RESULTS A total of 141 consecutive patients (124 women and 17 men) with a median age of 60.0 years (range, 56.7 to 61.2 years) were included. The cutoff size for a functional lymphatic vessel was determined to be 0.50 mm (i.e., lymphatic vessel0.5) from a total of 1048 lymphatic vessels. Significant differences were found between the number of lymphatic vessels0.5 anastomosed (zero to one, two to three, and greater than over equal to four lymphatic vessels0.5), the median post-lymphaticovenous anastomosis volume reduction (in milliliters) (p < 0.001), and themedian percentage volume reduction (p = 0.012). CONCLUSIONS Lymphatic vessel0.5 can be a valuable reference for lymphaticovenous anastomosis. Post-lymphaticovenous anastomosis outcome can be enhanced with the use of lymphatic vessel0.5 for anastomoses. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

Johnson Chia-Shen Yang,1,2 Lien-Hung Huang,1,2 Shao-Chun Wu,3,4 Yi-Chan Wu,1,4 Chia-Jung Wu,1,4 Chia-Wei Lin,1,4 Pei-Yu Tsai,1,4 Peng-Chen Chien,1,4 Ching-Hua Hsieh1,2 1Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; 2Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; 3Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; 4Chang Gung University College of Medicine, Taoyuan, TaiwanCorrespondence: Ching-Hua HsiehGraduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, 123 Dapi Road, Niaosong District, Kaohsiung City, 833, Taiwan, Tel +886-7-7317123, ext.8002, Fax +886-7-7354309, Email prs581126@gmail.comPurpose: This study aims at profiling the expression of dysregulated genes in circulating monocytes of patients with cancer-related lower limb lymphedema before and after treatment with supermicrosurgical lymphaticovenous anastomosis (LVA).Materials and Methods: This prospective longitudinal cohort study enrolled 51 women with post-treatment gynecological cancer, including those with unilateral lymphedema (study group, n = 25) and those without (control group, n = 26). Venous blood samples obtained from the study group before and after LVA and those from the controls were sent for next-generation sequencing, which was validated by real-time PCR. Dysregulated gene expression in the study group, relative to expression in the controls, was recorded before LVA. After one month, postoperative changes in the expression of the identified genes were evaluated. Protein-protein interaction (PPI) was used to investigate dysregulated genes whose expression returned to baseline levels after LVA.Results: Of the 148 preoperative dysregulated genes, which comprised 108 up- and 40 down-regulated genes, 78 genes, consisting of 69 up- and 9 down-regulated genes, showed post-LVA recovery to baseline levels. Through PPI analysis, five functional modules involving immunity, lipid metabolism, oxidative stress, transcriptional regulators, and tumor suppression, as well as six hub genes (CCL2, LPL, PDK4, FOXO3, EGR1, and DUSP5), were identified. Cross-linking and co-regulated genes between modules were also identified.Conclusion: Localized lymphedema leads to dysregulated gene expression in circulating monocytes. The current study is the first to identify the hub genes related to lymphedema and demonstrate the recovery of some dysregulated genes after LVA.Keywords: transcriptome, NGS, real-time PCR, hub gene, functional modules

Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p &lt, 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.

Background Lymphorrhea is probably the most appalling form of lymphedema and is difficult to treat. Intractable lymphorrhea is prone to infection because of skin breakdown. It is believed that supermicrosurgical lymphaticovenous anastomosis is unsuitable for treating such severe disease. Only a few lymphorrhea patients treated with lymphaticovenous anastomosis have been reported. Whether it can be used to treat lymphorrhea has remained inconclusive. Methods From September of 2015 to June of 2018, 105 patients underwent supermicrosurgical lymphaticovenous anastomosis (n = 746) in the authors' hospital. These patients are divided into the nonlymphorrhea group (three male and seven female patients) and the nonlymphedema group (lymphedema patients without lymphorrhea) (11 male and 84 female patients). Retrospective chart review with demographic data and intraoperative findings were recorded and analyzed. Post-lymphaticovenous anastomosis outcomes for lymphorrhea patients were also recorded. Results No significant differences were found in patient age, sex, or affected limbs between these two groups. As for intraoperative findings, no differences were found in the percentage of indocyanine green-enhanced lymphatic vessels (52.7 ± 41.1 percent versus 67.3 ± 36.7 percent; p = 0.227) or the pathologic changes of lymphatic vessels based on the normal, ectasis, contraction, and sclerosis type classification (2.2 ± 1.0 versus 2.1 ± 1.0; p = 0.893) between the lymphorrhea and nonlymphorrhea groups, respectively. The average follow-up period was 14.5 months (range, 3 to 31 months). Five lymphorrhea patients (50 percent) showed complete recovery without relapse; significant lymphorrhea reduction was found in three patients (30 percent), and two patients showed minimal improvements (20 percent). Conclusion With comparable functional lymphatic vessels identified in lymphorrhea patients, supermicrosurgical lymphaticovenous anastomosis is a viable option for lymphorrhea treatment, with satisfactory results. Clinical question/level of evidence Therapeutic, IV.

Background: The immediate challenges during microvascular reconstruction of hepatic artery (HAR) during liver transplantation (LT) can be many. Hence, in-order to give a cross sectional view of these problems this study over a period of 1 year, showing our routine practice, was taken up. Methods: From January 2015 to December 2015, a total of 133 LTs were performed in Kaohsiung Chang Gung Memorial Hospital, Taiwan. All hepatic artery (HA) reconstructions were performed by a microvascular surgeon under an operating microscope. Results: In the 133 patients, one artery was anastomosed in 123 (92.5%) patients, two in 9 (6.8%) patients and three in 1 (0.7%) of the patient. Eleven (8.3%) arteries were less than 2 mm in size (1–1.9 mm). There were intimal dissections (IDs) involving either the donor or the recipient arteries of mild to severe nature in 9 (6.8%) patients. Immediately following graft arterial anastomosis, either there was no flow or an intraoperative hepatic artery thrombosis (HAT) was found in nine (7.1%-8 LDLT, 4.8%-1 DDLT) patients. Immediate re-do anastomosis was done in all of these patients who did well in the follow-up. The overall post-operative success rate was 99.2%. One patient (0.8%) developed postoperative HAT due to infection during follow up and died due to sepsis. Conclusions: Small vessels or HA injury are the frequently encountered problems by a micro vascular surgeon. The other problems could be ID, need to do multiple reconstructions, immediate HAT and ability to re-do the HAR immediately.

BACKGROUND With the rising number of patients in advanced age receiving microsurgical procedures, coronary artery disease (CAD) and its challenging management is of increasing importance. Evidence based data concerning morbidity and mortality are rare. We present our experiences with this highly selected patient population and propose a preoperative assessment algorithm. PATIENTS AND METHODS Between January 2006 and May 2016, a total of 57 patients with CAD received 58 free flaps. Median age of our patients was 64 years (interquartile range 57.5-70.0). Squamous cell carcinoma was the reason for reconstruction in all cases. Defect of the buccal, gum, tongue, lip, trigone, palatal, and hypopharyngeal regions were reconstructed. Patient characteristics and comorbidities were recorded. We especially focused on the preoperative cardiac assessment and treatment of patients who were scheduled for microsurgical free tissue transfer such as medical history, cardiac risk assessment, and further cardiac testing such as Doppler-echocardiography and myocardial perfusion assessment. Intraoperative course as well as postoperative morbidity and mortality was described. RESULTS About 54.4% of the selected cohort received cardiac catheterization due to a clinical preoperative cardiac assessment performed individually by the cardiologist on duty. In total, 52 fasciocutaneous anterolateral thigh flaps, four osteocutaneous fibula flaps, and two radial forearm flaps were performed. The flap survival rate was 96.6%. The overall surgical complication rate was 28.1% (16 patients), mostly due to wound infections (seven cases) and partial flap necrosis (four cases). Three patients died, resulting in a mortality rate of 5.2%. CONCLUSION CAD patients receiving head and neck microsurgical reconstructions are still at high risk for adverse consequences due to surgery. The microsurgical community is requested to share the experience of those cases in order to develop reliable and evidence based statements of the perioperative risks and prognosis for these patients. We additionally introduce a standardized perioperative cardiac assessment and treatment algorithm for head and neck surgery patients with CAD.

Hepatic artery reconstruction (HAR) for liver transplantation is crucial for successful outcomes. We evaluated transplantation outcome improvement through continual technical refinements.HAR was performed in 1448 living donor liver transplants by a single plastic surgeon from 2008 to 2020. Difficult HARs were defined as graft or recipient hepatic artery ≤2 mm, size discrepancy (≥2 to 1), multiple hepatic arteries, suboptimal quality, intimal dissection of graft or recipient hepatic artery (HA), and immediate redo during transplantation. Technique refinements include early vessel injury recognition, precise HA dissection, the use of clips to ligate branches, an oblique cut for all HARs, a modified funneling method for size discrepancy, liberal use of an alternative artery to replace a pathologic HA, and reconstruction of a second HA for grafts with dual hepatic arteries in the graft.Difficult HARs were small HA (21.35%), size discrepancy (12.57%), multiple hepatic arteries (11.28%), suboptimal quality (31.1%), intimal dissection (20.5%), and immediate redo (5.18%). The overall hepatic artery thrombosis (HAT) rate was 3.04% in this series. The average HAT rate during the last 4 years (2017-2020) was 1.46% (6/408), which was significantly lower than the average HAT rate from 2008 to 2016 (39/1040, 3.8%) with a statistical significance (p = 0.025). Treatment for posttransplant HAT included anastomosis after trim back (9), reconstruction using alternatives (19), and nonsurgical treatment with urokinase (9).Careful examination of the HA under surgical microscope and selection of the appropriate recipient HA are key to successful reconstruction. Through continual technical refinements, we can reduce HA complications to the lowest degree.

Adductor canal block (ACB) has gained popularity for postoperative pain control after total knee arthroplasty (TKA). However, its role in TKA has been questioned recently. Our study aimed to clarify the role of ACB in reducing postoperative pain after TKA and to elucidate an optimal timing to perform ACB for better outcomes. We conducted a comprehensive review of the perioperative records of 652 patients undergoing primary TKA from January 2019 to December 2019. Patients were divided into three groups: Group A received general anesthesia without ACB, Group B received ACB before inducing general anesthesia, and Group C received ACB at the post-anesthesia recovery unit (PACU). Patients in Groups B and C had lower pain visual analogue scale (VAS) scores than patients in Group A at the PACU. Opioid consumption was similar among the three groups, however, a slightly higher dose was required by Group A patients. Higher VAS scores were recorded in the ward in Group A than in Groups B and C with the leg at rest. In addition, higher VAS scores were recorded in Group A than in Groups B and C with the leg in continuous passive motion (CPM) training. More patients in Group A (34.9%) quit their first CPM training after a few cycles than those in Groups B (27.0%) and C (20.1%). Group A patients required a higher per kg dose of opioids in the ward than Groups B and C patients. Additionally, the hourly consumption of sevoflurane was similar among the three groups of patients, while Group A and C patients required a higher hourly per kg dose of intraoperative opioids than Group B patients. More patients in Group A (67.6%) and C (61.7%) developed intraoperative hypertension than patients in Group B (52.7%). There was no significant difference in PON (postoperative nausea), POV (postoperative vomiting), postoperative dizziness, or patient satisfaction among the three groups of patients. Group A patients had a longer length of hospital stay compared to Group B and C patients. In conclusion, preoperative ACB could be a better choice for patients undergoing TKA as it decreases intraoperative opioid consumption and facilitates a stable hemodynamic state during surgery.

Background: Excess lymphedematous tissue causes excessive oxidative stress in lymphedema. Lymphaticovenous anastomosis (LVA) supermicrosurgery is currently emerging as the first-line surgical intervention for lymphedema. No data are available regarding the changes in serum proteins correlating to oxidative stress and antioxidant capacity before and after LVA. Methods: A total of 26 patients with unilateral lower limb lymphedema confirmed by lymphoscintigraphy were recruited, and venous serum samples were collected before (pre-LVA) and after LVA (post-LVA). In 16 patients, the serum proteins were identified by isobaric tags for relative and absolute quantitation-based quantitative proteomic analysis with subsequent validation of protein expression by enzyme-linked immunosorbent assay. An Oxidative Stress Panel Kit was used on an additional 10 patients. Magnetic resonance (MR) volumetry was used to measure t limb volume six months after LVA. Results: This study identified that catalase (CAT) was significantly downregulated after LVA (pre-LVA vs. post-LVA, 2651 ± 2101 vs. 1448 ± 593 ng/mL, respectively, p = 0.033). There were significantly higher levels of post-LVA serum total antioxidant capacity (pre-LVA vs. post-LVA, 441 ± 81 vs. 488 ± 59 µmole/L, respectively, p = 0.031) and glutathione peroxidase (pre-LVA vs. post-LVA, 73 ± 20 vs. 92 ± 29 U/g, respectively, p = 0.018) than pre-LVA serum. In addition, after LVA, there were significantly more differences between post-LVA and pre-LVA serum levels of CAT (good outcome vs. fair outcome, −2593 ± 2363 vs. 178 ± 603 ng/mL, respectively, p = 0.021) and peroxiredoxin-2 (PRDX2) (good outcome vs. fair outcome, −7782 ± 7347 vs. −397 ± 1235 pg/mL, respectively, p = 0.037) in those patients with good outcomes (≥40% volume reduction in MR volumetry) than those with fair outcomes (&lt, 40% volume reduction in MR volumetry). Conclusions: The study revealed that following LVA, differences in some specific oxidative stress markers and antioxidant capacity can be found in the serum of patients with lymphedema.

Background Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis. Patients and Methods Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA. Results A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897–0.992, p Conclusion Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status.

Background The anterolateral thigh (ALT) flap is a workhorse flap in head and neck cancer reconstruction. The anteromedial thigh (AMT) flap was developed as a rescue or alternative flap whenever the ALT flap is not available; however, the harvest of AMT flap seems to be more challenging in the sense that perforators have multiple variations. This study was designed to compare the outcome of the AMT and ALT flaps in head and neck cancer reconstruction. Methods A total of 1,547 ALT and 57 AMT flaps were used for head and neck cancer reconstruction between March 1, 2008 and February 28, 2017. Differences in patient and operative characteristics were compared between the patients undergoing AMT and ALT flap reconstruction. The primary outcome of the free flap was its survival or failure, while the second outcome was the associated complications. Results Compared to those who had ALT flap reconstruction, the patients who underwent AMT flap reconstruction had a higher rate of conditions that required reconstruction after previous cancer ablation and recurrence but a lower rate of primary cancer and deeply located cancer. Analysis of the 40 well-balanced pairs of propensity-score-matched patient cohorts revealed that the AMT flaps were associated with a significantly higher failure rate than the ALT flaps (15.0 vs. 0.0%, respectively; p = .026). Conclusion This study revealed that AMT flaps were associated with a significantly higher failure rate than ALT flaps in head and neck cancer reconstruction in the cohort of total patients and the propensity-score-matched cohorts.

Background For current lymphatico-venous anastomosis (LVA), the identification of "functional" lymphatic collecting vessels (LCVs) is mainly based on indocyanine green (ICG) lymphography. However, some of the non-ICG enhanced LCVs utilized for LVA were found to have visual lymphatic flow. Objectives Should non-ICG enhanced, but flow-positive LCVs be considered functional as well? Methods A retrospective study with 56 consecutive lymphedema patients (8 male/48 female) received LVA. LCVs were observed after ICG injection, before/after LVAs were performed. ICG enhancement and lymphatic flow in the LCVs were recorded and grouped as: Group A: all LCVs ICG(+) and flow(+); Group B: all LCVs ICG(+) and some were flow(+); Group C: some ICG(+) and some flow(+) LCVs; Group D: all LCVs ICG(-)but all flow(+); and Group E: all LCVs were both ICG(-) and flow(-). Results A total of 366 LCVs were identified, averaging 8.2 LVAs, 6.5 LCVs, and 4.7 veins per patient. A total of 33 LVAs were performed with 27 LCVs with no ICG enhancement from 7 patients (Group D). These patients were satisfied with their lymphedema improvements. Conclusion Lymphatic flow-positive but non-ICG enhanced LCVs, should also be considered as functional, thereby maximizing the number of functional LCVs for LVA.

Background: Electrical injuries are potentially devastating in many ways. This study aimed to profile the epidemiologic characteristics and outcome of these patients in a Level I trauma center in Southern Taiwan. Methods: A retrospective review of 34 (1.9%) patients with electrical injuries and admitted to the Kaohsiung Chang Gung Memorial Hospital Burn Center from 2009 to 2015 from all 23,705 hospitalized patients registered in the trauma registry system. The information such as patient's profile, injury characteristics and severity, description of the burn injury, associated injuries, expenditures, and outcomes were gathered. Results: There were 33 males and one female with an average age of 37.1 ± 10.4 years old. Twenty-eight cases (82.3%) were work related. The average total body surface area burned was 5.26%. The mean injury severity score was 9.8 with the median, and interquartile ranges (Q1–Q3) being 4 and 3.3–9.3. The average hospital length of stay (LOS) was 16.6 ± 14.3 days. Twenty-one patients required Intensive Care Unit (ICU) admission, and the average ICU LOS was 20.1 ± 16.2 days. Fourteen patients underwent operations with each patient averaging 2.5 operations. There were two cases of mortality (5.9%). Although the expenditure seemed to be higher in dealing with the electrical burn patients (n = 34) than the nonelectrical burn patients (n = 1727), there were no significant differences of the average total expenditure as well as the costs of operation, examination, and pharmaceuticals between the electrical burn patients and nonelectrical burn patients. Conclusions: Most of the electrical burn injuries are work related and may associated with injuries to different body regions. With a high incidence of ICU admission and the requirement of frequent operations, the electric burn injuries still carry high morbidities with the risk to mortality.

ObjectiveThis study was performed to share our clinical experience and provide treatment strategies for pediatric hand injuries caused by automatic cup-sealing machines in Taiwan.MethodsThirteen pediatric patients with an average age of 3.6 years were included in this retrospective study. Treatment was based on the location and depth of the injury and included full-thickness skin grafts, free or local flaps, and digital replantation. Some patients underwent contracture release during follow-up.ResultsThermal crush injuries affected the left hand in five patients and right hand in eight. Four patients with nine amputated fingers were treated by emergent digital replantation, four were treated by skin grafting, one was treated by nail bed repair, one underwent reconstruction with a local reversed dorsal digital and metacarpal island flap, one underwent reconstruction with a fascia graft for extensor tendon repair and pedicled groin flap coverage, and two underwent reconstruction with free anterolateral thigh fasciocutaneous flaps with a vascularized fascia lata graft for dorsal hand defects. All replanted fingers survived.ConclusionPediatric hand injuries, especially those caused by cup-sealing machines, can be devastating. Aggressive treatments including early reconstruction and rehabilitation should be performed for all pediatric hand injuries to achieve satisfactory functional restoration.

Background Bile duct complications hamper patient recovery from a transplant, curtail patient quality of life, and may impair the function and persistent survival of the allograft. The aim of this study is to compare the results of biliary reconstruction using 6-0 polypropylene and 6-0 polydioxanone. Methods A single-center retrospective study was performed on 133 patients who underwent microsurgical biliary reconstruction during living donor liver transplantation between November 2014 and December 2015. 6-0 polypropylene (Prolene) and 6-0 polydioxanone suture (PDS) were used for biliary reconstruction in 80 and 53 cases, respectively. The factors of age, sex, disease, and comorbidity were evenly distributed in these 2 groups. The average follow-up time was 43 months (36-50 months). There were 49 right lobe grafts and 31 left lobe grafts in the polypropylene group and 27 right lobe grafts, 25 left lobe grafts, and 1 left lateral segment in the polydioxanone group. Results The overall biliary complication rate was 11.25% in the polypropylene group. The overall biliary complication rate was 11.32% in the polydioxanone group. All biliary complications were managed successfully, and no mortality was observed. There was no statistically significant difference between complication rates with the use of different suture material (P = .990). Conclusion The theoretical advantages of polydioxanone over polypropylene in biliary reconstruction could not be explained with this study.

Background:The purpose of this study was to compare the clinical outcomes and donor-site morbidity between the suprafascial and subfascial harvesting of anterolateral thigh flaps.Methods:Sixty-one patients who underwent free flap reconstruction (30 suprafascial and 31 subfascial anterolateral thigh

Introduction Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity. Methods A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included. Results A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%). Conclusion Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

Background Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem. Methods From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy. Results The average flap size was 29 × 8 cm (range: 25–31 × 6–10 cm2). An average of 2.6 perforators was included in each flap (2–4 perforators/flap). All flaps survived. One venous thrombosis was noted and salvaged after thrombolectomy and vein graft. The mean follow-up period was 25 months. The fistula rate was 21.4% (three patients). One fistula never healed because of early recurrence; one fistula healed after surgical intervention; and one fistula need a loco-regional flap for secondary reconstruction. Three postoperative strictures were noted (21.4%). Conclusion For the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

Lymphaticovenous anastomosis is one of the main surgical treatments nowadays for alleviating lymphedema. A successful lymphaticovenous anastomosis relies on being able to identify "functional" lymphatic collecting vessels that are still capable of transporting lymph, and a nearby vein that is, ideally, reflux-free. This is a retrospective study. A total of 28 lymphedema patients were enrolled from October of 2016 to March of 2017 in Kaohsiung Chang Gung Hospital, Kaohsiung, Taiwan. A noninvasive vein visualizer was used to preselect reflux-free veins for lymphaticovenous anastomosis from five female patients. As a control, the total number of veins used for lymphaticovenous anastomoses without the use of a vein visualizer from 23 consecutive lymphedema patients was also recorded and compared. In the experimental group, a total of 12 of 13 veins (92 percent sensitivity) preselected by using the VeinViewer were confirmed to be reflux-free intraoperatively during lymphaticovenous anastomosis. In the control group, 21 of 56 veins (37.5 percent sensitivity) showed no venous reflux. Statistical analysis with the chi-square test showed a value of p < 0.001 (number needed to treat = 2.706). The odds of identifying reflux-free veins can be increased significantly with the use of a vein visualizer. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, II.

Fournier's gangrene can lead to extensive defects of the perineoscrotal area with exposure of the testes. Such defect poses challenging tasks for both functional and cosmetic reconstruction. Due to its proximity, medial thigh skin appeared to be the most versatile donor site for perineoscrotal reconstruction. In this report, we present a case of reconstruction of a large perineoscrotal defect because of Fournier's gangrene using a posteromedial thigh (PMT) perforator propeller flap. A 58 year-old male who suffered from Fournier's gangrene resulted in a scrotal defect of 10 × 12 cm(2) with a large dead space. A pedicled PMT propeller flap measuring 9 × 23 cm(2) with two perforators that originated from the profunda femoris artery (PFA) was harvested for scrotal defect reconstruction and dead space obliteration. The flap survived completely, with no recipient or donor site morbidity. The length of followup was 3 months and was uneventful. The pedicled PMT propeller flap may be considered as a valid option for perineoscrotal reconstruction.

Background. The aim of this study was to profile TLR4/NF-κB-responsive microRNAs (miRNAs) and their potential target genes in the skeletal muscles of mice following ischemia-reperfusion injury.Methods. Thigh skeletal muscles of C57BL/6,Tlr4−/−, andNF-κB−/−mice isolated based on femoral artery perfusion were subjected to ischemia for 2 h and reperfusion for 0 h, 4 h, 1 d, and 7 d. The muscle specimens were analyzed with miRNA arrays. Immunoprecipitation with an argonaute 2- (Ago2-) specific monoclonal antibody followed by whole genome microarray was performed to identify mRNA associated with the RNA-silencing machinery. The potential targets of each upregulated miRNA were identified by combined analysis involving the bioinformatics algorithm miRanda and whole genome expression.Results. Three TLR4/NF-κB-responsive miRNAs (miR-15a, miR-744, and miR-1196) were significantly upregulated in the muscles following ischemia-reperfusion injury. The combined in silico and whole genome microarray approaches identified 5, 4, and 20 potential target genes for miR-15a, miR-744, and miR-1196, respectively. Among the 3 genes (Zbed4, Lrsam1,andDdx21) regulated by at least 2 of the 3 upregulated miRNAs,Lrsam1andDdx21are known to be associated with the innate immunity pathway.Conclusions. This study profiled TLR4/NF-κB-responsive miRNAs and their potential target genes in mouse skeletal muscle subjected to ischemia-reperfusion injury.

Postoperative vascular compromise is a common but critical complication requiring emergent re-exploration, and remains a chief cause of free flap failure. This study investigated the relationship between postanesthetic shivering (PAS) and the development of postoperative complications associated with free flap reconstruction. One hundred thirty-six patients who underwent head and neck cancer resection and free flap reconstruction were retrospectively enrolled. Fifteen patients were assigned to the PAS group, while the others were assigned to the non-PAS (NPAS) group. The odds ratios of acute re-exploration or total failure of the free flap in the PAS group was 3.5 and 14.9, respectively. The dose of meperidine was positively correlated with PAS prevention in our statistical ROC curve analysis. The minimum effective dose of meperidine for PAS prevention was 0.35 mg/kg with 75% sensitivity and 60% specificity. These findings indicate that an optimal dose of meperidine could prevent PAS, which is shown to be associated with a decrease in the incidence of the early post-surgical re-exploration rate of these free flaps related to circulatory compromise. © 2013 Wiley Periodicals, Inc. Microsurgery 34:106–111, 2014.

Reducing the expression of endothelial cell adhesion molecules (ECAMs) is known to decrease inflammation-induced vascular complications. In this paper we looked at whether statins can reduce inflammation-induced ECAM expression after lipopolysaccharide (LPS) treatment in endothelial cells. Human umbilical vein endothelial cells (HUVECs) were pretreated with different concentrations of simvastatin, atorvastatin, and rosuvastatin and subsequently exposed to 5 μg/ml LPS. Semi-quantitative RT-PCR analysis was used to measure the mRNA expression of ECAMs, including VCAM-1, ICAM-1, and E-selectin. VCAM-1 mRNA appeared to be the only target that was affected by the statins, with its expression being partially and almost completely reduced by simvastatin at 50 and 125 μM concentrations, respectively, and only partially reduced by atorvastatin, but not reduced by rosuvastatin. VCAM-1 protein production was inhibited by simvastatin at concentrations from 5 to 125 μM. Leukocyte–endothelial cell adhesion assay revealed that simvastatin could inhibit the adhesion of labelled U937 cells to the HUVEC monolayer. This study showed that simvastatin reduces VCAM-1 expression in HUVECs exposed to LPS and decreases leukocyte–endothelial cell adhesion.

After liver transplantation (LT), re-exploration of the abdomen to check for bleeding is sometime required. Our study aimed to identify the predictive factors by analysis of preoperative and intraoperative presentations that may impact the re-exploration for hemostasis.We selected 522 consecutive recipients from the Liver Transplant Program database and medical records between January 1, 1994 and December 1, 2009 in our hospital. Demographic data (age, sex, body mass index, weight, MELD score), preoperative laboratory tests (Hb, platelet, albumin, bilirubin, INR, APTT), and intraoperative presentations (ascites and blood loss, crystalloids, 5% albumin infused, blood products used (such as LPRBC, RBC, FFP, platelet, cryoprecipitate), urine output, Hb at end of operation, and anesthesia) were collected for primary comparison. Potential predictors found by univariate comparison at p0.1 were put into a multiple binary logistic regression model.Thirty-eight (7.3%) recipients required re-exploration for hemostasis after LDLT; 80% needed re-exploration only once. In univariate analysis, recipients transfused with FFP10 ml/kg had a 4.2-fold increased risk of re-exploration (p0.001). Thirteen potential predictors by univariate comparison at p0.1 were selected into a multiple binary logistic regression. Fresh frozen plasma (FFP) transfused was the sole predictor.Each elevation of 1ml of transfused FFP per kg is associated with a 1.033-fold increased incidence of re-exploration for hemostasis. Patients transfused with more than 10 ml/kg FFP during LT require more intensive management within 72 hours due to increase risk of postoperative bleeding.

Single flap for complex hypopharyngoesophageal and anterior neck skin defect reconstruction is still a challenge for reconstructive surgeons. Herein, we present five patients, with advanced hypopharyngeal cancer and anterior neck skin invasion, which received a single anterolateral thigh (ALT) fasciocutaneous flap for composite inner pharyngeal and outer skin defect reconstruction after wide composite resection. Two ALT flaps were divided into two distinct paddles supplied by two or more separate perforators, one part for reconstructing the inner pharyngeal defect and another for neck skin coverage. Three ALT flaps only supplied by one sizable perforator could not be divided and de-epithelization of mid-part had to be done to reconstruct both defects with the single flap. The results revealed survival of all flaps. There were no flap loss, fistulas, or bleeding complications. All patients recovered uneventfully and could eat a soft diet to regular diet postoperatively. In conclusion, one-staged reconstruction of complex pharyngoesophageal and external skin defects after extensive oncological resection is feasible using a single ALT fasciocutaneous free flap.

To profile the expression of microRNAs (miRNAs) and their potential target genes in the soleus muscles after denervation and reinnervation of the sciatic nerve in rats.The 4 months denervated and reinnervated soleus muscles were analyzed with Agilent Rat miRNA array to detect the expressed miRNAs against those from the sham control. These differentially expressed miRNAs were applied for hierarchical cluster analysis using average linkage and Pearson correlation as a measure of similarity. A combined approach using computational prediction by the miRanda algorithm and the Agilent Whole Rat Genome 4× 44K oligo microarray experiment was performed to identify the potential target genes of these up-regulated miRNAs. Gene ontology (GO) analysis of these potential target genes into one of the three ontologies, biological process, molecular function, or cellular component, was performed and compared between the denervated and reinnervated muscles.Thirty-six and 39 miRNAs of 350 rat miRNAs tested were significantly up-regulated in the denervated and reinnervated muscles, respectively. The expressed miRNAs in these two groups were similar but with different folds, and the unsupervised hierarchy clustering was able to separate the samples into denervation and reinnervation groupings. In the GO analysis, all three categories indicated a considerable reduced number of the potential target genes of the up-regulated miRNAs and less fraction of differentially expressed genes in most of the GO terms in the reinnervated muscle.This study demonstrated a different involvement of miRNAs and their potential target genes in the soleus muscle after denervation and after reinnervation of the sciatic nerve in a rat model.

Background. A noninvasive method for monitor- ing in cases of pharyngoesophageal defects reconstruction with the anterolateral thigh flap is presented. Methods. Seventeen patients underwent reconstruction from 2005 to 2007. In 16 patients, the distal stump of the de- scending branch of lateral circumflex femoral artery (LCFA) was left on the skin surface covered with a transparent film dressing and monitoring was performed by direct observation of the pulsation. In the 17th patient, the pedicle emerged from the transverse branch of the LCFA and dissection of the distal stump for monitoring was impossible; therefore, he was excluded from the study. Results. Cessation of the pulsation of the stump was noticed immediately postoperatively in 1 patient because of occlusion of the arterial anastomosis and in a second case 15 hours postoperatively due to a neck hematoma that caused collapse of the vein of the pedicle. Both flaps were salvaged. Conclusion. The proposed method of monitoring is simple, reliable, costless, and easily interpreted by the nursing staff. V

Alternative choices were proposed to facilitate a successful reconstruction when no sizable skin perforator is encountered in anterolateral thigh (ALT) flap dissection.Alternative choices such as harvest of a tensor fascia latae (TFL) flap, elevation of an anteromedial thigh (AMT) flap, use of a free muscle component with full-thickness skin graft coverage, and use of another donor flap were performed.Between August 1995 and December 2006, 10 of 923 patients underwent ALT flap elevation with no sizable perforators. Of them, each of the 4 patients received reconstruction with a free TFL flap, 3 with an AMT flap, 2 with a free muscle flap, and 1 with a radial forearm flap. There was 1 TFL flap failure due to postoperative venous thrombosis, and the defect was repaired by an AMT flap.When no sizable perforator is encountered, successful reconstruction could still be achieved by the proposed alternative choices.

The versatile use of the free radial forearm flap for the reconstruction of pharyngoesophageal defects has been proven ideal in previous studies. However, the monitoring of flap viability when buried underneath the skin in head and neck surgery still posed technical difficulties. An innovative monitoring method for the buried free radial forearm flap by using distal radial vessel stump elevated over the skin is to be presented here. Eighteen patients received free radial forearm flap reconstruction for their pharyngoesophageal defects after tumor ablation during June 2003 to March 2005. All patients were males; ages ranged from 36 to 71 years, averaging 53.2 years old. Fourteen skin tubing and patches were designed for the defects. The pharyngoesophageal defects ranged from 6 to 12 cm in length, averaging 8.5 cm. The free radial forearm flap was designed to allow a distal radial vessel stump about 3 cm long, which was then elevated above the skin in the neck region after insetting to act as a monitor for the viability of the buried flap. The flap viability can be easily demonstrated simply by observing continuous pulsation coming from the distal radial vessel stump with naked eyes. The monitoring stump was then ligated and resected at bedside after the viability of the buried flap was insured 2 weeks postoperatively. All free flap transfers were successful. One case was found with kinking of artery during the operation and it was corrected immediately. One case with venous insufficiency was detected 13 hours after the operation and the flap was salvaged successfully by thrombectomy and venous reanastomosis. Three patients developed temporary fistula and healed spontaneously after conservative treatment. Deep neck infections were found in patients, and recovered after aggressive antibiotic treatment. Two patients had esophagocutaneous fistula and needed secondary surgical intervention. The use of distal radial vessel stump as a monitor for the buried flap is a reliable method in head and neck surgery. It not only allows easy monitoring, no further donor site morbidity, but it also eliminates the need for special monitoring device.

Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity.A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included.A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%).Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment. © 2016 Wiley Periodicals, Inc. Microsurgery 38:222-229, 2018.

Circumferential hypopharyngeal defect with simultaneous skin defect can pose complicated reconstructive challenge for reconstructive microsurgeons. Our experience with the versatile inverted-omega flap tubing design is proposed to accommodate such problem.From 2012 to 2015, 13 anterolateral thigh (ALT) flaps and one anteromedial thigh (AMT) flap were harvested for reconstruction of circumferential hypopharyngeal defects with skin defects in 14 patients. All patients were males except one. Patient age ranged from 42 to 67 years (average, 53.1 years). Fifty-seven percent were recurrent cases. All but one patient received preoperative chemoradiotherapy.The average flap size was 29 × 8 cm (range: 25-31 × 6-10 cmFor the circumferential hypopharyngeal defect with simultaneous neck skin defect, this inverted-omega ALT tubing design offers an alternative choice for such complicated reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:51-59, 2018.