- Email: [email protected]
The hemi-stenting technique in lymphaticovenular anastomosis
438 are based on a negative pressure gradient, leading to the drainage of the lymphatic fluid into the venous network. cshaped lymphaticovenular anastomosis is a new configuration, which is a venous flow-sparing technique, such as pshaped lymphaticovenular anastomosis.
Disclosure None.
Conflict of interest None.
References 1. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010;125:935e43. 2. Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast Reconstr Surg 1990;85:64e74 [discussion 75e76]. 3. Starling EH. On the absorption of fluids from the connective tissue spaces. J Physiol (Lond) 1895;19:312e26. 4. Sabin FR. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am J Anat 1902;1:367e91. 5. Wigle JT, Harvey N, Detmar M, et al. An essential role for Prox1 in the induction of the lymphatic endothelial cell phenotype. EMBO J 2002;21:1505e13.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected]
Correspondence and communications technique is to visualize the lumen of small and translucent vessels, and avoid technical errors. However, it was demonstrated that intimal injuries, secondary to intravascular stents, induce intimal hyperplasia and thrombosis.3e5 To minimize the risk of postoperative thrombosis, after lymphaticovenular anastomosis, we developed the hemistenting technique. The technique requires a 5 mm nylon monofilament Prolene (Ethicon, Inc., Johnson and Johnson, Somerville, New Jersey, USA), used as an intravascular sheath into the lumen of lymphatic vessels. The diameter of this monofilament is variable, according to the caliber of the vessel. A 6/0 monofilament is used for lymphatic vessels, which caliber is superior than 0.5 mm. A 7/0 monofilament is used when the caliber is inferior than 0.5 mm. The monofilament sheath is inserted after having transected the lymphatic vessel, with microsurgical instruments. The placement is very gently and precisely performed to minimize endovascular injuries. The lymphaticovenular anastomosis is performed, without inserting the monofilament sheath into the venule (Figure 1). The stent is removed after an average of 3 stitches (Video). A supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2012.08.048. The aim of the microsurgical hemi-stenting technique is to visualize the lumen of translucent vessels and facilitate the microvascular anastomosis. Most of time, the lumen of transected lymphatic vessels can be visualized with high magnification. Then, the hemi-stenting technique is required in difficult situations when the lumen is not visible, but not systematically. The method can be used for end-to-end or end-to-side anastomosis. From November 2010 to August 2012, 234 lymphaticovenular anastomosis were performed in 52 patients. 19 lymphaticovenular anastomosis (8.1%), in 6 patients (11.5%), required the hemi-stenting technique. These 6 patients were treated by low-dose aspirin (75 mg/24 h) during 4 weeks to avoid
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.031
The hemi-stenting technique in lymphaticovenular anastomosis Dear Sir, The clinical effectiveness of lymphaticovenular anastomosis for chronic lymphedema have been proved and reported since the two latter decades. However, due to technical difficulties, supermicrosurgical anastomosis of vessels, inferior than 0.8 mm in caliber, are not routinely used. To simplify microvascular anastomosis, the intravascular stenting technique was introduced with Wei et al. for venous microsurgical anastomosis,1 and by Narushima et al. for lymphaticovenular anastomosis.2 The aim of the
Figure 1 Intraoperative view of the hemi-stenting technique in an end-to-end lymphaticovenular anastomosis. A 5 mm nylon monofilament 6/0 Prolene is used as a stent. The stent is inserted into the lumen of the lymphatic vessel, but not into the venule. In this case, the anastomosis is performed between a 0.65 mm lymphatic vessel and a 0.75 mm subdermal venule.
Correspondence and communications postoperative microthrombosis.4 The average volume reduction rate was 24.9% (range, 7.1e37.5) (p Z 0.002) for the patients treated with the hemi-stenting technique, and 27.4% (range, 6.4e48.8) (p Z 0.0005) for the patients treated without the hemi-stenting technique. No significant difference was found between the 2 groups of patients. The hemi-stenting technique avoids endovascular intimal injuries of the venules, used for lymphaticovenular anastomosis. Minimizing these endovascular injuries is important for the patency rate of the microsurgical anastomosis. Indeed, it was demonstrated that intimal trauma leads to a vascular smooth muscle cell (VSMC) proliferation and a neointima proliferation.3e5 This phenomenon is responsible for a lower patency rate and a risk of thrombosis. The other advantage of the hemi-stenting technique is technical: the stent is easily removed out of the lymphatic vessel, without damaging the endovascular part of the venule (Video). As the venule wall is particularly visible under high magnification, comparing to the translucent aspect of the lymphatic vessels, there is no technical difficulty to perform lymphaticovenular anastomosis with the hemi-stenting technique. In conclusion, the hemi-stenting technique is a reproducible and easy method which can help the performance of lymphaticovenular anastomosis. This method avoids endovascular intimal injuries of the venules, and limits the risk of thrombosis. It is not systematically used, but can be very helpful when the lumen of the lymphatic vessels is not precisely visualized under high magnification.
Conflict of interest None.
Disclosure None.
References 1. Wei FC, Mancer K, Zuker RM. The temporary stent technique: an easier method of micro-venous anastomosis. Br J Plast Surg 1982;35:92e5. 2. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010;125:935e43. 3. Indolfi C, Avvedimento EV, Di Lorenzo E, et al. Activation of cAMP-PKA signaling in vivo inhibits smooth muscle cell proliferation induced by vascular injury. Nat Med 1997;3:775e9. 4. Tesfamariam B. Platelet function in intravascular device implant-induced intimal injury. Cardiovasc Revasc Med 2008;9: 78e87. 5. Curcio A, Torella D, Indolfi C. Mechanisms of smooth muscle cell proliferation and endothelial regeneration after vascular injury and stenting: approach to therapy. Circ J 2011;75:1287e96.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected]
439 Crown Copyright ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.048
Keloid scars and treatment with Botulinum Toxin Type A: The Belfast experience Dear Sir, There is no universally accepted treatment regimen for Keloid scars.1 A few reports in the literature have reported benefits with pressure therapy, intralesional steroid injections, laser therapy, radiation therapy or a last resort of intralesional scar excision.2 Intralesional injection of Botulinum Toxin Type A in to the treatment resistant keloid is a less famous treatment method that has been successfully reported in the literature. The mechanism of action of Botulinum in treating keloid scars is largely unknown. Botulinum has been shown to minimise facial scarring by reducing the tensile force across the healing wound.3,4 Zhibo et al. link Botulinum with regression of scar growth by inhibition of the fibroblast cellcycle leading to improvement in the overall appearance.3,4 Uyesugi et al., declare that Botulinum successfully treats the neuropathic symptoms associated with keloid5 scars.
Results A single surgeon has treated Keloid scars using Botulinum Toxin Type A in Belfast over the past 5 years. We have used Botulinum Type A in 12 patients during this period. The average age was 30 years (9e47 yrs) with no family history of keloids. Ten patients were Caucasians, one Chinese and one South Asian. Four patients developed keloids after skin surgery and one after a burn. The rest were idiopathic. Nine patients had keloid scars over the central chest/sternum. The remaining had scars on the neck, thigh and cheek. The patients were treated for an average of one and a half year (0e6 years) with conventional treatments prior to commencing Botulinum therapy. Eight patients had concurrent alternating intra-dermal triamcinolone therapy to supplement the treatment with Botulinum. The patients had between 20 and 100 International Units of Botulinum Toxin injected at any one time, depending on the size and the location of the keloid scar. On average, it took 11 months of repeated injections to completely flatten the keloid scar (2 monthse43 months) (Figure 1). Visible reduction in size, colour, consistency, symptoms and further progression was recorded using the Vancouver scale. Two patients developed recurrences adjacent to previously treated areas. One patient developed skin atrophy that lead to ulceration and eventual recurrence due to concurrent steroid therapy. Another patient who received Intense Pulsed Light (IPL) therapy, developed an ulcer leading to recurrence.
Disclosure None.
Conflict of interest None.
References 1. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010;125:935e43. 2. Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast Reconstr Surg 1990;85:64e74 [discussion 75e76]. 3. Starling EH. On the absorption of fluids from the connective tissue spaces. J Physiol (Lond) 1895;19:312e26. 4. Sabin FR. On the origin of the lymphatic system from the veins and the development of the lymph hearts and thoracic duct in the pig. Am J Anat 1902;1:367e91. 5. Wigle JT, Harvey N, Detmar M, et al. An essential role for Prox1 in the induction of the lymphatic endothelial cell phenotype. EMBO J 2002;21:1505e13.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected]
Correspondence and communications technique is to visualize the lumen of small and translucent vessels, and avoid technical errors. However, it was demonstrated that intimal injuries, secondary to intravascular stents, induce intimal hyperplasia and thrombosis.3e5 To minimize the risk of postoperative thrombosis, after lymphaticovenular anastomosis, we developed the hemistenting technique. The technique requires a 5 mm nylon monofilament Prolene (Ethicon, Inc., Johnson and Johnson, Somerville, New Jersey, USA), used as an intravascular sheath into the lumen of lymphatic vessels. The diameter of this monofilament is variable, according to the caliber of the vessel. A 6/0 monofilament is used for lymphatic vessels, which caliber is superior than 0.5 mm. A 7/0 monofilament is used when the caliber is inferior than 0.5 mm. The monofilament sheath is inserted after having transected the lymphatic vessel, with microsurgical instruments. The placement is very gently and precisely performed to minimize endovascular injuries. The lymphaticovenular anastomosis is performed, without inserting the monofilament sheath into the venule (Figure 1). The stent is removed after an average of 3 stitches (Video). A supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2012.08.048. The aim of the microsurgical hemi-stenting technique is to visualize the lumen of translucent vessels and facilitate the microvascular anastomosis. Most of time, the lumen of transected lymphatic vessels can be visualized with high magnification. Then, the hemi-stenting technique is required in difficult situations when the lumen is not visible, but not systematically. The method can be used for end-to-end or end-to-side anastomosis. From November 2010 to August 2012, 234 lymphaticovenular anastomosis were performed in 52 patients. 19 lymphaticovenular anastomosis (8.1%), in 6 patients (11.5%), required the hemi-stenting technique. These 6 patients were treated by low-dose aspirin (75 mg/24 h) during 4 weeks to avoid
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.031
The hemi-stenting technique in lymphaticovenular anastomosis Dear Sir, The clinical effectiveness of lymphaticovenular anastomosis for chronic lymphedema have been proved and reported since the two latter decades. However, due to technical difficulties, supermicrosurgical anastomosis of vessels, inferior than 0.8 mm in caliber, are not routinely used. To simplify microvascular anastomosis, the intravascular stenting technique was introduced with Wei et al. for venous microsurgical anastomosis,1 and by Narushima et al. for lymphaticovenular anastomosis.2 The aim of the
Figure 1 Intraoperative view of the hemi-stenting technique in an end-to-end lymphaticovenular anastomosis. A 5 mm nylon monofilament 6/0 Prolene is used as a stent. The stent is inserted into the lumen of the lymphatic vessel, but not into the venule. In this case, the anastomosis is performed between a 0.65 mm lymphatic vessel and a 0.75 mm subdermal venule.
Correspondence and communications postoperative microthrombosis.4 The average volume reduction rate was 24.9% (range, 7.1e37.5) (p Z 0.002) for the patients treated with the hemi-stenting technique, and 27.4% (range, 6.4e48.8) (p Z 0.0005) for the patients treated without the hemi-stenting technique. No significant difference was found between the 2 groups of patients. The hemi-stenting technique avoids endovascular intimal injuries of the venules, used for lymphaticovenular anastomosis. Minimizing these endovascular injuries is important for the patency rate of the microsurgical anastomosis. Indeed, it was demonstrated that intimal trauma leads to a vascular smooth muscle cell (VSMC) proliferation and a neointima proliferation.3e5 This phenomenon is responsible for a lower patency rate and a risk of thrombosis. The other advantage of the hemi-stenting technique is technical: the stent is easily removed out of the lymphatic vessel, without damaging the endovascular part of the venule (Video). As the venule wall is particularly visible under high magnification, comparing to the translucent aspect of the lymphatic vessels, there is no technical difficulty to perform lymphaticovenular anastomosis with the hemi-stenting technique. In conclusion, the hemi-stenting technique is a reproducible and easy method which can help the performance of lymphaticovenular anastomosis. This method avoids endovascular intimal injuries of the venules, and limits the risk of thrombosis. It is not systematically used, but can be very helpful when the lumen of the lymphatic vessels is not precisely visualized under high magnification.
Conflict of interest None.
Disclosure None.
References 1. Wei FC, Mancer K, Zuker RM. The temporary stent technique: an easier method of micro-venous anastomosis. Br J Plast Surg 1982;35:92e5. 2. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg 2010;125:935e43. 3. Indolfi C, Avvedimento EV, Di Lorenzo E, et al. Activation of cAMP-PKA signaling in vivo inhibits smooth muscle cell proliferation induced by vascular injury. Nat Med 1997;3:775e9. 4. Tesfamariam B. Platelet function in intravascular device implant-induced intimal injury. Cardiovasc Revasc Med 2008;9: 78e87. 5. Curcio A, Torella D, Indolfi C. Mechanisms of smooth muscle cell proliferation and endothelial regeneration after vascular injury and stenting: approach to therapy. Circ J 2011;75:1287e96.
Benoit Ayestaray Jean-Baptiste Andreoletti Department of Plastic and Reconstructive Surgery, Breast Institute, 15 av Jean Jaure`s, 90000 Belfort, France E-mail address: [email protected]
439 Crown Copyright ª 2012 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2012.08.048
Keloid scars and treatment with Botulinum Toxin Type A: The Belfast experience Dear Sir, There is no universally accepted treatment regimen for Keloid scars.1 A few reports in the literature have reported benefits with pressure therapy, intralesional steroid injections, laser therapy, radiation therapy or a last resort of intralesional scar excision.2 Intralesional injection of Botulinum Toxin Type A in to the treatment resistant keloid is a less famous treatment method that has been successfully reported in the literature. The mechanism of action of Botulinum in treating keloid scars is largely unknown. Botulinum has been shown to minimise facial scarring by reducing the tensile force across the healing wound.3,4 Zhibo et al. link Botulinum with regression of scar growth by inhibition of the fibroblast cellcycle leading to improvement in the overall appearance.3,4 Uyesugi et al., declare that Botulinum successfully treats the neuropathic symptoms associated with keloid5 scars.
Results A single surgeon has treated Keloid scars using Botulinum Toxin Type A in Belfast over the past 5 years. We have used Botulinum Type A in 12 patients during this period. The average age was 30 years (9e47 yrs) with no family history of keloids. Ten patients were Caucasians, one Chinese and one South Asian. Four patients developed keloids after skin surgery and one after a burn. The rest were idiopathic. Nine patients had keloid scars over the central chest/sternum. The remaining had scars on the neck, thigh and cheek. The patients were treated for an average of one and a half year (0e6 years) with conventional treatments prior to commencing Botulinum therapy. Eight patients had concurrent alternating intra-dermal triamcinolone therapy to supplement the treatment with Botulinum. The patients had between 20 and 100 International Units of Botulinum Toxin injected at any one time, depending on the size and the location of the keloid scar. On average, it took 11 months of repeated injections to completely flatten the keloid scar (2 monthse43 months) (Figure 1). Visible reduction in size, colour, consistency, symptoms and further progression was recorded using the Vancouver scale. Two patients developed recurrences adjacent to previously treated areas. One patient developed skin atrophy that lead to ulceration and eventual recurrence due to concurrent steroid therapy. Another patient who received Intense Pulsed Light (IPL) therapy, developed an ulcer leading to recurrence.