• Archives of Reconstructive Microsurgery
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• v.22 no.1
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• pp.33-37
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• 2013

Purpose: The concept and development of perforator free flaps have led to significant advances in microsurgery. Ongoing developments in perforator free flap surgery are aimed at reducing complications and improving surgical outcomes. The aim of this study was to evaluate the effectiveness and application of supermicrosurgery in free flap surgery. Materials and Methods: A total of 267 patients with soft tissue defects of the lower extremity due to various etiologies from January, 2007 to January, 2013. The patients received either an anterolateral thigh free flap (n=83), a superficial circumflex iliac artery free flap (n=152), an upper medial thigh free flap (n=19), or a superior gluteal artery perforator free flap (n=13). Microanastomosis was performed using a perforator-to-perforator technique, either end-to-end or end-to-side. Results: The mean postoperative follow up period was eight months (range: one to 16 months) and flap loss occurred in 11 cases out of 267. All cases of flap loss occurred within two weeks of surgery due to either arterial insufficiency (n=5) or venous congestion (n=6). Conclusion: Supermicrosurgery enables the selection of the most efficient perforator for microanastomosis at the defect site. It also reduces the time required for dissection of recipient vessels, and reduces the possibility of injury to major vessels. Microsurgery using a vessel of less than 1 mm has been reported to increase the risk of flap failure; however, using the most advanced surgical tools and developing experience in the technique can produce success rates similar to those found in the literature.

• Archives of Plastic Surgery
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• v.48 no.4
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• pp.427-432
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• 2021

The conventional approach of looking down a microscope to perform microsurgical procedures is associated with occupational injuries, anti-ergonomic postures, and increased tremor and fatigue, all of which predispose microsurgeons to early retirement. Recently, three-dimensional (3D) visualization of real-time microscope magnification has been developed as an alternative. Despite its commercial availability, no supermicrosurgical procedures have been reported using this technology to date. Lymphovenous anastomoses (LVAs) often require suturing vessels with diameters of 0.2-0.8 mm, thus representing the ultimate microsurgical challenge. After performing the first documented LVA procedure using 3D-augmented visualization in our unit and gaining experience with this technique, we conducted an anonymized in-house survey among microsurgeons who had used this approach. The participants considered that 3D visualization for supermicrosurgery was equivalent in terms of handling, optical detail, depth resolution, and safety to conventional binocular magnification. This survey revealed that team communication, resident education, and ergonomics were superior using 3D digital hybrid visualization. Postoperative muscle fatigue, tremor, and pain were also reduced. The major drawbacks of the 3D visualization microscopic systems are the associated costs, required space, and difficulty of visualizing the lymphatic contrast used.

• Maxillofacial Plastic and Reconstructive Surgery
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• v.33 no.5
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• pp.375-384
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• 2011

Purpose: The advent of microsurgical technique and instruments, particularly in the field of perforator flap and supermicrosurgery, which have expanded the scope of microsurgery. However, supermicroanastomosis without any compression, tension, or distortions must be achieved to reach successful outcomes. Small-caliber vessels, such as those with an internal diameter less than 0.2 mm, are susceptible to inadvertent twisting of the anastomosis. In this study, using the superficial inferior epigastric artery (SIEA)-based flap model in Sprague-Dawley (SD) rats, we evaluated the acceptable limits of twisting effects on supermicroanastomotic sites. Methods: A total of 20 supermicroanastomoses were performed using the SIEA-based flap model in 10 male SD rats, 10-weeks-of-age, weighing 300~350 g. Rats were divided into five groups of two with four flaps as follows: 1) sham, 2) control group with end to end SIEA arterial supermicroanastomosis, 3) experimental I (EA1) with $90^{\circ}$ twisting, 4) experimental II (EA2) with $180^{\circ}$ twisting, and 5) experimental III (EA3) with $270^{\circ}$ twisting of the supermicroanastomosis. Each SIEA was anastomosed using six 11-0 $Ethilon^{(R)}$ (Ethicon Inc. Co., NJ, USA) stitches except in the sham group where the SIEA was only clamped with Supermicro vascular $clamps^{(R)}$ (S&T, Neuhausen, Switzerland) for 20 minutes. Results: The anastomosed arterial patency showed no remarkable changes according to doppler waveforms measured with a Smardop 45 Doppler System (Hadeco Inc., Kawasaki, Japan). The pulsatility index (PI) was increased at postoperative day 10 in the EA2 and EA3 groups, and the resistance index (RI) showed no statistically significant difference between preoperative and postoperative values at 10 days. Histologic specimens from the EA3 group showed increased tunica media necrosis, convolution of the internal elastic lamina, densely packed platelets, fibrin, and erythrocytes. Flap viability and anastomosed vessel patency were not significantly affected by the degree of arterial twisting in this study, other than in the EA3 group where minor effects on arterial patency of the microanastomoses were encountered. Conclusion: It appears that minor twisting on small caliber arteries, used in supermicroanastomoses, can be tolerated. However, twisting should be avoided as much as possible, and more than $180^{\circ}$ twisting must be prevented in clinical practice.

• Archives of Plastic Surgery
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• v.49 no.4
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• pp.549-553
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• 2022

Chylothorax is a rare disease and massive lymph fluid loss can cause life-threatening condition such as severe malnutrition, weight loss, and impaired immune system. If untreated, mortality rate of chylothorax can be up to 50%. This is a case report of a 3-year-old child with iatrogenic chylothorax. Despite conservative treatment and procedures, like perm catheter insertion, the patient failed to improve the respiratory symptoms over 3 months of period. As an alternative to surgical option, such as pleurodesis and thoracic duct ligation which has high complication rate, the patient underwent lymphovenous anastomosis (LVA) and lymph node to vein anastomosis (LNVA). Follow-up at fourth month showed clear lungs without breathing difficulty despite perm catheter removal. This is the first report to show the effectiveness of LVA and LNVA against iatrogenic chylothorax.

• Archives of Plastic Surgery
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• v.50 no.4
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• pp.422-431
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• 2023

Background Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema. Methods A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year. Results Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected. Conclusion Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.

• Archives of Plastic Surgery
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• v.41 no.6
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• pp.693-701
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• 2014

Background A thin perforator flap is one of the best methods for covering defects. This study aimed to revisit and further test the rapidly advancing field of flap thinning techniques. Methods We performed two cadaveric studies to test the known flap thinning methods, and then applied these methods to a clinical series. In the first study, five cadavers were used to observe the anatomical relation of the perforator with the subdermal plexuses and the subcutaneous fat layer by injecting a colored latex solution. The second study was done on four cadavers independently from the first study. Last, a clinical series was performed on 15 patients. Results The areolar fat lobules of 10 anterolateral thigh perforator (ALT), seven deep inferior epigastric artery perforator (DIEAP), and six thoracodorsal artery perforator (TAP) flaps were dissected to reduce the flap thickness guided by the colored vascular pattern. On average, the ALT, DIEAP, and TAP flaps were reduced to $32.76%{\pm}9.76%$, $37.01%{\pm}9.21%$, and $35.42%{\pm}9.41%$, respectively. In the second study, the areolar fat lobules were directly dissected in six ALT, six TAP, and four MSAP flaps, and an average reduction in flap thickness of $53.41%{\pm}5.64%$, $52.30%{\pm}2.88%$, and $47.87%{\pm}6.41%$, respectively, was found. In the clinical series, 13 out of the 15 cases yielded satisfactory outcomes with an average thickness reduction of $37.91%{\pm}7.15%$. Conclusions These multiple studies showed that the deep fat layer could be safely removed to obtain a thin yet viable perforator flap. This evidence suggests that the macroscopic flap thinning technique can achieve thin flaps. Surgeons should consider this technique before embracing the latest technique of supermicrosurgery.

• Archives of Plastic Surgery
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• v.45 no.5
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• pp.466-469
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• 2018

The highly contoured nature of the nose and the abundant free margin makes it especially difficult to reconstruct. In this report, we describe the use of a new helical rim free flap technique for the reconstruction of full-thickness nasal alar defects via supermicrosurgery. Briefly, after a wide excision with a margin of 0.7 cm, an alar defect with a size of $1{\times}1{\times}0.5cm$ was obtained, which included the full thickness of the skin, mucosa, and lower lateral cartilage. Vessel dissection was performed in a straightforward manner, starting from the incision margin for flap harvest, without any further dissection for reach the greater trunk of the superficial temporal artery. The flap was inset in order to match the contour of the contralateral ala. We closed the donor site via rotation and advancement. No donor site morbidity was observed, despite the presence of a small scar that could easily be covered with hair. The alar contour was satisfactory, and the patient was satisfied with the results. The supermicrosurgical technique did not require further dissection to identify the vessels for anastomosis, leading to better cosmetic outcomes and a reduced operating time.

• Archives of Plastic Surgery
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• v.47 no.4
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• pp.365-370
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• 2020

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.