Microsurgery最新文献

Lymphovenous anastomosis (LVA) is an effective surgical treatment for inguinal lymphorrhea, a complication that can occur after surgery involving vessels. LVA, however, requires a suitable vein for anastomosis near the leaking lymphatic vessel, which is sometimes difficult to secure. Here we report the successful treatment of a refractory ulcer with lymphorrhea by anastomosis of a flap vein to the lymphatic vessel concerned, along with flap closure. The patient was a 26-year-old male who developed a lymphatic leak in the right inguinal region following cannula removal after mechanical circulatory support for fulminant cardiomyopathy. He received conservative therapy but developed an infected femoral artery aneurysm, leading to replacement with the femoral vein. However, because of the persistent, intractable ulcer with exposed graft vessels and continued lymphatic leakage, pedicled flap reconstruction and LVA were planned. A 14 × 6.5 cm spindle-shaped pedicled deep inferior epigastric perforator flap was elevated from the right lower abdomen with branches reserved for use in LVA, rotated 180° through the subcutaneous tunnel, and migrated to the ulcer site. The source of lymphorrhea in the ulcer was identified by indocyanine green (ICG) lymphangiography, and the lymphatic vessels were anastomosed to a branch of the flap pedicle vein. ICG lymphangiography confirmed unimpeded venous flow without the stagnation of lymphatic fluid. At 6 months postoperatively, there was no evidence of ulceration or recurrence of lymphorrhea or lymphedema. In cases of lymphorrhea with refractory ulceration, there often are no suitable veins for LVA in the wound area due to scarring or adhesions. The present case demonstrates the use of a flap pedicle vein to solve this problem, potentially offering a new treatment option for lymphorrhea with extensive ulceration.

Free fillet flap reconstruction transfers composite tissue from an unsalvageable limb to repair a separate defect. We report a case of free fillet flaps based on the posterior tibial artery (PTA) and anterior tibial artery (ATA). A 41-year-old man was crushed under a truck; his right leg suffered an open tibia and fibula fracture (Gustilo IIIB) with extensive soft tissue loss, while his left foot was amputated at the tarsal level. He initially underwent Chopart-level amputation of the left limb, which was subsequently revised to a below-knee amputation. Two free fillet flaps were harvested from the amputated limb: one based on the PTA (15 × 13 cm) and the other based on the ATA (20 × 8 cm). Two chain-linked fillet flaps via flow-through anastomosis were used to cover the soft tissue defect exposing the right tibia. Postoperatively, partial necrosis occurred in the ATA-based fillet flap, which healed after reoperation. The patient regained mobility with a prosthesis. Free chain-linked fillet flaps harvested from a limited amputation segment are a feasible and useful option for reconstructing complex soft tissue defects without additional donor site morbidity.

Head and neck lymphedema is a common complication of head and neck cancer treatment. Lymphovenous bypass is a promising surgical treatment but may not be an option for all patients after radiotherapy due to the obliteration of local lymphatic targets for bypass. We aim to present vascularized lymph node transfer (VLNT) as a solution to this problem. We report the case of a 38-year-old patient with Stage 2 face and neck lymphedema after treatment for T4aN1oral squamous cell carcinoma, who had no targets for lymphovenous bypass. The patient was treated with a 6 by 14 cm fasciocutaneous VLNT based on the left superficial circumflex iliac artery and vein, to the right facial vein and facial artery. The patient was given a low-dose heparin infusion, placed in a head bolster to prevent neck rotation, and discharged with low-dose aspirin. 4.5 months after free flap reconstruction, the patient underwent revision of the flap including indocyanine green lymphatic mapping, thinning with lymph-sparing liposuction, and re-advancement with Z-plasty for contour. At 11 months, the patient experienced a reduction of swelling, improvement of symptoms, and no further need for compression and manual lymphatic drainage. The area of greatest mobility impairment was resurfaced with flap skin, improving subjective tightness. Indocyanine green imaging at 4 months and 11 months revealed linear lymphatics traversing from the facial skin into the flap. Facial dermal thickness on ultrasound decreased from 1.43 to 1.09 mm between 4 and 11 months postoperatively. Fasciocutaneous VLNT has the potential to restore lymphatic drainage, improving swelling and tightness for patients with head and neck lymphedema who do not have lymphatic targets for bypass. Future studies on head and neck lymphedema should routinely employ ultrasound measurement of dermal thickness as an objective measure.