- Email: [email protected]
The value of Q-switched Nd:YAG laser after patent blue-enhanced lymphaticovenular anastomosis
Correspondence and communications
1157
Conflict of interests/funding None.
Acknowledgments The authors would like to thank Dr Richard Goodwin, Consultant Radiologist, Bhavana Jha and Sarah Hazelden, Physiotherapists, at Norfolk and Norwich University Hospital, Norwich, UK for having offered support and help out of duties to record and collect data and images.
References 1. Zhang SX, Ho GT, Liu ZJ. Further study on the vascular basis for the reimplantation of the hand amputated through the palm. Surg Radiol Anat 1995;17:47e52. 2. Silcott GR, Polich VL. Palmar arch arterial reconstruction for the salvage of ischemic fingers. Am J Surg 1981;142:219e25. 3. Jones NF, Raynor SC, Medsger TA. Microsurgical revascularisation of the hand in scleroderma. Br J Plast Surg 1987;40:264e9. 4. Greenberg BM, Cuadros CL, Jupiter JB. Interpositional vein grafts to restore the superficial palmar arch in severe devascularising injuries of the hand. J Hand Surg Am 1988;13: 753e7. 5. Tonkin MA, Ames EL, Wolff TW, Larsen RD. Transmetacarpal amputations and replantation: the importance of the normal vascular anatomy. J Hand Surg Br 1988;13:204e9.
C.H. Thomson A.K. Shah G. Ko ¨hler R.M. Haywood A. Figus Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK E-mail addresses: [email protected], [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.014
The value of Q-switched Nd:YAG laser after patent blue-enhanced lymphaticovenular anastomosis Dear Sir, Lymphoedema microsurgery has known a renewed interest since the introduction of supermicrosurgical techniques by Koshima et al.1 However, lymphatic vessels are difficult to
Figure 1 59-year-old female having a clinical Stage III breast cancer-related lymphoedema of the right upper limb. She was treated by 4 p-shaped patent blue-enhanced lymphaticovenular anastomosis. Postoperative view 3 months after surgery: a 5 cm2 blue skin colouration is visible at the anterior part of the lower forearm. The scar maturation is inflammatory at this stage.
individualise because of their small calibre and translucent appearance. Patent blue dye is a good and safe solution to enhance the lymphatic network before performing lymphaticovenular anastomosis.2,3 The main issue of this technique is to be responsible for a remaining skin staining at the injection site in some cases. To overcome this problem, we established a protocol using a Pulsed Nd:YAG laser in a Q-switched mode (wavelength 1064/532 nm) to treat the remaining skin colouration. In a series of 72 patients treated by patent blueenhanced lymphaticovenular anastomosis, between November 2010 and December 2012, 11 (15.3%) patients did not have a complete blue-staining skin resorption. Eight (11.1%) patients were bothered with the remaining skin colouration. They were treated with the Q-switched Nd:YAG laser. An average of 2 months postoperatively was required before starting the Q-switched laser session, as the average blue-staining skin resorption is 30 days.3 Six (8.3%) patients had a remaining staining on the upper limb. They were previously treated by lymphaticovenular anastomosis for breast cancer-related lymphoedema (Figure 1). Two (2.7%) had a primary lymphoedema of the lower limb. Among these eight patients, three (37.5%) had
1158
Correspondence and communications
Conflict of interest None.
Disclosure None.
EBM level Level V.
References
Figure 2 Postoperative view after 2 sessions of Q-switched Nd:YAG Laser at the injection site (8 months postoperatively) : a complete colouration removal is obtained. Scars are less visible. Lymphoedema circumference has decreased of 4 cm at the arm, 3 cm at the forearm, 1 cm at the wrist and 1 cm at the hand.
a complete skin dye removal after 1 session and five (62.5%) after two sessions of Q-switched laser (Figure 2). The second session was always scheduled after an interval of 6 weeks. For these eight patients, no adverse effect (dyschromia or burn) occurred. Sun protection was required for 12 months after the last laser session. Daily skin massages with a moisturising cream was also needed for 2 months. The mechanism of the colouration resorption by the Q-switched laser is due to the division of patent blue molecules by the emitted light. Then, macrophages eliminate definitively the remaining particles with a delay of 2 weeks.4 The only contraindication of this method is for patients having dark skin (phototypes V and VI). Indeed, the emitted light (wavelength 1064/ 532 nm) is stopped by melanin. Darker skin phototypes are also more susceptible to adverse effects, such as hyperchromia and burn.5 However, we did not observe any remaining skin colouration in phototypes V and VI patients treated by patent-blue lymphaticovenular anastomosis. A remaining blue skin colouration is the main issue of patent blue-enhanced lymphaticovenular anastomosis. This colouration can be ungracious, especially on the forearm, in the case of breast cancer-related lymphoedema patients. The Q-switched Nd:YAG laser is a noninvasive and effective method to remove definitively this postoperative adverse effect.
1. Koshima I, Inagawa K, Urushibara K, et al. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000;16: 432e7. 2. Yap YL, Lim J, Shim TWH, Naidu S, Ong WC, Lim TC. Patent blue dye in lymphaticovenular anastomosis. Ann Acad Med Singapore 2009;38(8):704e6. 3. Ayestaray B, Bekara F, Andreoletti JB. Patent blue-enhanced lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2013;66(3):382e9. 4. Bencini PL, Cazzaniga S, Tourlaki A, Galimberti MG, Naldi L. Removal of tattoos by q-switched laser: variables influencing outcome and sequelae in a large cohort of treated patients. Arch Dermatol 2012;148(12):1364e9. 5. Rossi AM, Perez MI. Treatment of hyperpigmentation. Facial Plast Surg Clin North Am 2011;19(2):313e24.
Benoit Ayestaray Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France E-mail address: [email protected] Louis Attalah Department of Dermatology, Besanc¸on University Hospital, 2, Place Saint Jacques, 25030 Besanc¸on, France Crown Copyright ª 2013 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.2013.03.022
Urethral stent in hypospadias repair Dear Sir, Hypospadias repair is a well-accepted procedure to return form and function to these patients. However,
1157
Conflict of interests/funding None.
Acknowledgments The authors would like to thank Dr Richard Goodwin, Consultant Radiologist, Bhavana Jha and Sarah Hazelden, Physiotherapists, at Norfolk and Norwich University Hospital, Norwich, UK for having offered support and help out of duties to record and collect data and images.
References 1. Zhang SX, Ho GT, Liu ZJ. Further study on the vascular basis for the reimplantation of the hand amputated through the palm. Surg Radiol Anat 1995;17:47e52. 2. Silcott GR, Polich VL. Palmar arch arterial reconstruction for the salvage of ischemic fingers. Am J Surg 1981;142:219e25. 3. Jones NF, Raynor SC, Medsger TA. Microsurgical revascularisation of the hand in scleroderma. Br J Plast Surg 1987;40:264e9. 4. Greenberg BM, Cuadros CL, Jupiter JB. Interpositional vein grafts to restore the superficial palmar arch in severe devascularising injuries of the hand. J Hand Surg Am 1988;13: 753e7. 5. Tonkin MA, Ames EL, Wolff TW, Larsen RD. Transmetacarpal amputations and replantation: the importance of the normal vascular anatomy. J Hand Surg Br 1988;13:204e9.
C.H. Thomson A.K. Shah G. Ko ¨hler R.M. Haywood A. Figus Department of Plastic and Reconstructive Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK E-mail addresses: [email protected], [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.03.014
The value of Q-switched Nd:YAG laser after patent blue-enhanced lymphaticovenular anastomosis Dear Sir, Lymphoedema microsurgery has known a renewed interest since the introduction of supermicrosurgical techniques by Koshima et al.1 However, lymphatic vessels are difficult to
Figure 1 59-year-old female having a clinical Stage III breast cancer-related lymphoedema of the right upper limb. She was treated by 4 p-shaped patent blue-enhanced lymphaticovenular anastomosis. Postoperative view 3 months after surgery: a 5 cm2 blue skin colouration is visible at the anterior part of the lower forearm. The scar maturation is inflammatory at this stage.
individualise because of their small calibre and translucent appearance. Patent blue dye is a good and safe solution to enhance the lymphatic network before performing lymphaticovenular anastomosis.2,3 The main issue of this technique is to be responsible for a remaining skin staining at the injection site in some cases. To overcome this problem, we established a protocol using a Pulsed Nd:YAG laser in a Q-switched mode (wavelength 1064/532 nm) to treat the remaining skin colouration. In a series of 72 patients treated by patent blueenhanced lymphaticovenular anastomosis, between November 2010 and December 2012, 11 (15.3%) patients did not have a complete blue-staining skin resorption. Eight (11.1%) patients were bothered with the remaining skin colouration. They were treated with the Q-switched Nd:YAG laser. An average of 2 months postoperatively was required before starting the Q-switched laser session, as the average blue-staining skin resorption is 30 days.3 Six (8.3%) patients had a remaining staining on the upper limb. They were previously treated by lymphaticovenular anastomosis for breast cancer-related lymphoedema (Figure 1). Two (2.7%) had a primary lymphoedema of the lower limb. Among these eight patients, three (37.5%) had
1158
Correspondence and communications
Conflict of interest None.
Disclosure None.
EBM level Level V.
References
Figure 2 Postoperative view after 2 sessions of Q-switched Nd:YAG Laser at the injection site (8 months postoperatively) : a complete colouration removal is obtained. Scars are less visible. Lymphoedema circumference has decreased of 4 cm at the arm, 3 cm at the forearm, 1 cm at the wrist and 1 cm at the hand.
a complete skin dye removal after 1 session and five (62.5%) after two sessions of Q-switched laser (Figure 2). The second session was always scheduled after an interval of 6 weeks. For these eight patients, no adverse effect (dyschromia or burn) occurred. Sun protection was required for 12 months after the last laser session. Daily skin massages with a moisturising cream was also needed for 2 months. The mechanism of the colouration resorption by the Q-switched laser is due to the division of patent blue molecules by the emitted light. Then, macrophages eliminate definitively the remaining particles with a delay of 2 weeks.4 The only contraindication of this method is for patients having dark skin (phototypes V and VI). Indeed, the emitted light (wavelength 1064/ 532 nm) is stopped by melanin. Darker skin phototypes are also more susceptible to adverse effects, such as hyperchromia and burn.5 However, we did not observe any remaining skin colouration in phototypes V and VI patients treated by patent-blue lymphaticovenular anastomosis. A remaining blue skin colouration is the main issue of patent blue-enhanced lymphaticovenular anastomosis. This colouration can be ungracious, especially on the forearm, in the case of breast cancer-related lymphoedema patients. The Q-switched Nd:YAG laser is a noninvasive and effective method to remove definitively this postoperative adverse effect.
1. Koshima I, Inagawa K, Urushibara K, et al. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg 2000;16: 432e7. 2. Yap YL, Lim J, Shim TWH, Naidu S, Ong WC, Lim TC. Patent blue dye in lymphaticovenular anastomosis. Ann Acad Med Singapore 2009;38(8):704e6. 3. Ayestaray B, Bekara F, Andreoletti JB. Patent blue-enhanced lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2013;66(3):382e9. 4. Bencini PL, Cazzaniga S, Tourlaki A, Galimberti MG, Naldi L. Removal of tattoos by q-switched laser: variables influencing outcome and sequelae in a large cohort of treated patients. Arch Dermatol 2012;148(12):1364e9. 5. Rossi AM, Perez MI. Treatment of hyperpigmentation. Facial Plast Surg Clin North Am 2011;19(2):313e24.
Benoit Ayestaray Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France E-mail address: [email protected] Louis Attalah Department of Dermatology, Besanc¸on University Hospital, 2, Place Saint Jacques, 25030 Besanc¸on, France Crown Copyright ª 2013 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.2013.03.022
Urethral stent in hypospadias repair Dear Sir, Hypospadias repair is a well-accepted procedure to return form and function to these patients. However,