- Email: [email protected]
Inguinal seroma prevention after superficial circumflex iliac artery perforator flap harvest using non-microsurgical lympho-venous shunt
Correspondence and communications
1479
Funding None.
Conflicts of interest None declared.
Ethics The study was conducted under a University of Tokyo Hospital institutional review-board - approved protocol, and all patients gave written consent to the study. Figure 1 Pedicle dissection of a SCIP flap in the left groin region. Even if the superficial branch is damaged (white arrow), flap elevation can be resumed by switching the pedicle to the deep branch of the SCIA (yellow arrow), which can always be found under the deep fascia, medial to the sartorius muscle.
be elongated by use of branches given off from the SCIA.2 The flap elevation does not require muscle or nerve dissection, and this contributes to its minimal donor site morbidity. The donor site scar is located at an unexposed region and can be hidden by underwear.3 However, when compared with other commonly used free flaps such as anterolateral thigh (ALT) flaps and thoracodorsal artery perforator (TAP) flaps, pedicle dissection can be more tedious because the diameter of the SCIA is relatively small, usually around 1.0 mm, even at its most proximal part, where it is given off from the external iliac artery. The superficial branch of the SCIA runs through the superficial adipose layer, thus extra care should be taken not to damage the vessel. On the other hand, the deep branch of the SCIA lies beneath the deep fascia. Due to this definite anatomical landmark, the deep branch is less likely to be damaged inadvertently. Therefore, during pedicle dissection of a SCIP flap, even if the superficial branch is damaged (Figure 1, white arrow), flap elevation can be resumed by switching the pedicle to the deep branch of the SCIA (Figure 1, yellow arrow), which can always be found under the deep fascia, medial to the sartorius muscle.4 Another option would be switching the pedicle to the superficial inferior epigastric artery, but this would require elongation of the incision for pedicle dissection. Elevation of a SCIP flap may be technically difficult due to small diameter of its pedicle, but knowing that the deep branch of the SCIA always exist and can be used as backup can lower the surgeon’s stress level during pedicle dissection.
Disclaimers and disclosure of conflicts of interest
References 1. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004 Jan;113(1):233e40. 2. Yoshimatsu H, Yamamoto T, Iida T. Pedicle elongation technique of superficial circumflex iliac artery perforator flap. J Plast Reconstr Aesthet Surg 2015 Mar;68(3):e61e2. 3. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg 2013 Oct;71(4): 380e3. 4. Flaps Groin, Strauch Berish, Yu Han-Liang, Chen Zhon-Wei, Liebling Ralph. Atlas of microvascular surgery: anatomy and operative approaches; 1993:120e2.
Hidehiko Yoshimatsu Takumi Yamamoto Takuya Iida Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.041
Inguinal seroma prevention after superficial circumflex iliac artery perforator flap harvest using non-microsurgical lympho-venous shunt
None. Dear Sir,
Prior presentations None.
Superficial circumflex iliac artery perforator (SCIP) flap is a type of skin flap that is becoming popular in the area of reconstructive surgery.1 Dissection of the proximal
1480
Correspondence and communications
Figure 1 The lymphatic vessel with the most leakage was inserted into a nearby subcutaneous vein. Indocyanine green lymphography showed no lymph leakage. The red arrow shows an anastomosis site.
pedicle of the SCIP flap around the femoral vessels can cause rapture of lymphatic vessels and subsequent seroma. It’s better to preserve as many lymphatic vessels as possible in the groin region. However, it’s not always the case when the lymphatic vessels are wrapped tightly around the flap’s pedicle. To address this challenge, we developed a new method for the prevention of inguinal seroma. First, the groin region was put under indocyanine green (ICG) lymphography after the elevation of a SCIP flap; 0.2 ml of 2.5% ICG was injected in three areas (medial, middle and lateral parts of the superior border of the patella), and lymphography images were obtained using a near-infrared camera device.2e4 Lymph leaking points were visualized and marked under ICG lymphography navigation. The lymphatic vessel with the most leakage was inserted into a nearby large (approximately 3.0 mm) subcutaneous vein using a 7-0 prolene; lymphovenus shunt was performed without operating microscopes or surgical loupes. ICG lymphography was again performed to make sure the leakage was no longer visible (Figure 1). Other lymphatic vessels with minor leakage were ligated.5 Since lymphatic vessel and surrounding tissue are merely inserted into a large subcutaneous vein, this macroscopic operation can be performed without any special instruments and completed within 10 min. Clot might be formed within the anastomosed vein, but it never defeat the purpose of prevention of seroma; anastomosis site thrombosis also can prevent lymph leakage. Although further researches are needed, our method may be useful
for the prevention of inguinal seroma after SCIP flap or groin flap elevation.
Ethics Conducted under the University of Tokyo Hospital ethics committee-approved protocol.
Conflicts of interest None.
Disclaimers and disclosure None.
Funding None.
References 1. Iida T, Yoshimatsu H, Yamamoto T, et al. A free vascularized iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2013;66(11):1596e9. 2. Yamamoto T, Narushima M, Doi K, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity
Correspondence and communications staging system using dermal backflow patterns. Plast Reconstr Surg 2011;127(5):1979e86. 3. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green (ICG)-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow (DB) patterns. Plast Reconstr Surg 2011;128(4): 941e7. 4. Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green (ICG) lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow (DB) stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128(4):314ee21e. 5. Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014; 67(11):1573e9.
1481 Yukiko Yoshino Takumi Yamamoto Ko Fujisawa Takafumi Saito Ryohei Ishiura Takuya Iida Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected] DOI of original j.bjps.2013.03.031
article:
http://dx.doi.org/10.1016/
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.06.007
1479
Funding None.
Conflicts of interest None declared.
Ethics The study was conducted under a University of Tokyo Hospital institutional review-board - approved protocol, and all patients gave written consent to the study. Figure 1 Pedicle dissection of a SCIP flap in the left groin region. Even if the superficial branch is damaged (white arrow), flap elevation can be resumed by switching the pedicle to the deep branch of the SCIA (yellow arrow), which can always be found under the deep fascia, medial to the sartorius muscle.
be elongated by use of branches given off from the SCIA.2 The flap elevation does not require muscle or nerve dissection, and this contributes to its minimal donor site morbidity. The donor site scar is located at an unexposed region and can be hidden by underwear.3 However, when compared with other commonly used free flaps such as anterolateral thigh (ALT) flaps and thoracodorsal artery perforator (TAP) flaps, pedicle dissection can be more tedious because the diameter of the SCIA is relatively small, usually around 1.0 mm, even at its most proximal part, where it is given off from the external iliac artery. The superficial branch of the SCIA runs through the superficial adipose layer, thus extra care should be taken not to damage the vessel. On the other hand, the deep branch of the SCIA lies beneath the deep fascia. Due to this definite anatomical landmark, the deep branch is less likely to be damaged inadvertently. Therefore, during pedicle dissection of a SCIP flap, even if the superficial branch is damaged (Figure 1, white arrow), flap elevation can be resumed by switching the pedicle to the deep branch of the SCIA (Figure 1, yellow arrow), which can always be found under the deep fascia, medial to the sartorius muscle.4 Another option would be switching the pedicle to the superficial inferior epigastric artery, but this would require elongation of the incision for pedicle dissection. Elevation of a SCIP flap may be technically difficult due to small diameter of its pedicle, but knowing that the deep branch of the SCIA always exist and can be used as backup can lower the surgeon’s stress level during pedicle dissection.
Disclaimers and disclosure of conflicts of interest
References 1. Koshima I, Nanba Y, Tsutsui T, et al. Superficial circumflex iliac artery perforator flap for reconstruction of limb defects. Plast Reconstr Surg 2004 Jan;113(1):233e40. 2. Yoshimatsu H, Yamamoto T, Iida T. Pedicle elongation technique of superficial circumflex iliac artery perforator flap. J Plast Reconstr Aesthet Surg 2015 Mar;68(3):e61e2. 3. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg 2013 Oct;71(4): 380e3. 4. Flaps Groin, Strauch Berish, Yu Han-Liang, Chen Zhon-Wei, Liebling Ralph. Atlas of microvascular surgery: anatomy and operative approaches; 1993:120e2.
Hidehiko Yoshimatsu Takumi Yamamoto Takuya Iida Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan E-mail address: [email protected] ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.05.041
Inguinal seroma prevention after superficial circumflex iliac artery perforator flap harvest using non-microsurgical lympho-venous shunt
None. Dear Sir,
Prior presentations None.
Superficial circumflex iliac artery perforator (SCIP) flap is a type of skin flap that is becoming popular in the area of reconstructive surgery.1 Dissection of the proximal
1480
Correspondence and communications
Figure 1 The lymphatic vessel with the most leakage was inserted into a nearby subcutaneous vein. Indocyanine green lymphography showed no lymph leakage. The red arrow shows an anastomosis site.
pedicle of the SCIP flap around the femoral vessels can cause rapture of lymphatic vessels and subsequent seroma. It’s better to preserve as many lymphatic vessels as possible in the groin region. However, it’s not always the case when the lymphatic vessels are wrapped tightly around the flap’s pedicle. To address this challenge, we developed a new method for the prevention of inguinal seroma. First, the groin region was put under indocyanine green (ICG) lymphography after the elevation of a SCIP flap; 0.2 ml of 2.5% ICG was injected in three areas (medial, middle and lateral parts of the superior border of the patella), and lymphography images were obtained using a near-infrared camera device.2e4 Lymph leaking points were visualized and marked under ICG lymphography navigation. The lymphatic vessel with the most leakage was inserted into a nearby large (approximately 3.0 mm) subcutaneous vein using a 7-0 prolene; lymphovenus shunt was performed without operating microscopes or surgical loupes. ICG lymphography was again performed to make sure the leakage was no longer visible (Figure 1). Other lymphatic vessels with minor leakage were ligated.5 Since lymphatic vessel and surrounding tissue are merely inserted into a large subcutaneous vein, this macroscopic operation can be performed without any special instruments and completed within 10 min. Clot might be formed within the anastomosed vein, but it never defeat the purpose of prevention of seroma; anastomosis site thrombosis also can prevent lymph leakage. Although further researches are needed, our method may be useful
for the prevention of inguinal seroma after SCIP flap or groin flap elevation.
Ethics Conducted under the University of Tokyo Hospital ethics committee-approved protocol.
Conflicts of interest None.
Disclaimers and disclosure None.
Funding None.
References 1. Iida T, Yoshimatsu H, Yamamoto T, et al. A free vascularized iliac bone flap based on superficial circumflex iliac perforators for head and neck reconstruction. J Plast Reconstr Aesthet Surg 2013;66(11):1596e9. 2. Yamamoto T, Narushima M, Doi K, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity
Correspondence and communications staging system using dermal backflow patterns. Plast Reconstr Surg 2011;127(5):1979e86. 3. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green (ICG)-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow (DB) patterns. Plast Reconstr Surg 2011;128(4): 941e7. 4. Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green (ICG) lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow (DB) stage and concept of subclinical lymphedema. Plast Reconstr Surg 2011; 128(4):314ee21e. 5. Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014; 67(11):1573e9.
1481 Yukiko Yoshino Takumi Yamamoto Ko Fujisawa Takafumi Saito Ryohei Ishiura Takuya Iida Department of Plastic and Reconstructive Surgery, the University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected] DOI of original j.bjps.2013.03.031
article:
http://dx.doi.org/10.1016/
ª 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2015.06.007