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Ultramicrosurgical lymphaticovenular anastomosis using intradermal venules as recipient vessels
Correspondence and communications
279
Ultramicrosurgical lymphaticovenular anastomosis using intradermal venules as recipient vessels
Switzerland). 1 end-to-end LVA was performed between the 0.15 mm venule and the 0.15 mm lymphatic vessel. 2 endto-end LVAs were performed between the 0.2 mm venule and the 0.35 mm lymphatic vessel (Figure 1(b), Video). The following is the supplementary video related to this article:
Dear Sir, Lymphaticovenular anastomoses (LVAs) have become a widespread method to treat chronic lymphedema. The concept of supermicrosurgery was introduced with the advance in microsurgical sutures of lymphatic vessels, which caliber is usually included between 0.3 and 0.8 mm.1,2 However, it is sometimes possible that no subdermal venule is adjacent to lymphatic vessels, leading supermicrosurgical LVAs impossible. We report a case of a 82 year old patient having a worsening Campisi clinical stage III lymphedema of the left upper limb. She did not wear daily elastic stocking and bandage, and stopped lymph drainage. The duration of her lymphedema was 8 years. The mean circumferential excess rate was 14.7%. She was treated by patent-blue enhanced lymphaticovenular anastomoses under local anesthesia.3,4 The caliber of subdermal vessels was measured with a professional scaled ruler (Shinwa Sokutei Co., Ltd., Sapporo Eigyosho, Japan). Superficial lymphatic vessels, which caliber was 0.35 mm and 0.15 mm, were dissected at the anteromedial part of her forearm (Figure 1(a), Video). No adjacent subdermal venule was found at the operative site. Two intradermal venules were dissected into the dermis, above these lymphatic vessels (Figure 1(a), Video). The first venule was 0.15 mm. The second venule was 0.2 mm. Ultramicrosurgical LVAs (using < 0.3 mm vessels) were performed with Ultrafine Microsurgical instruments (Medicon and Co., Tuttlingen, Germany), and 12-0 nylon monofilament on a 50 mm 3/8 needle (S&T, S&T AG, Neuhausen,
Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2013.07.029. 2 years after surgery, the average circumferential differential reduction rate was 8.6%. The average volume differential reduction rate was 16.2% (Figure 2). The reduction of the pinch test at the forearm was 6 mm. Soft tissues were softer, the pinch test was thinner, and the subjective skin sensibility was improved. This clinical case proves the interest of intradermal venules to perform LVAs without necessity of changing the incision site. Anatomically, intradermal venules are distributed in a large network based on the dermal vascular plexus (DVP).5 One anatomical particularity is that they are completely independent of dermal arteries. Their diameter is inferior to the caliber of functional lymphatic vessels. It is usually included between 0.05 and 0.25 mm. The concept of vascular ultramicrosurgery can be defined as microanastomosis of vessels which caliber is strictly inferior to 0.3 mm. In this report, intradermal venules appear to be clinically valuable to perform ultramicrosurgical LVAs, and present as a salvage solution, when no subdermal venule is adjacent to lymphatic vessels.
EBM level Level V.
Disclosure None.
Figure 1 (a) Intraoperative view: one intradermal venule (red arrow) is visualized through the dermis. Two patent blue-enhanced lymphatic vessels of 0.35 mm (yellow star) and 0.15 mm (blue star) have been dissected. (b) Intraoperative view: 1 end-to-end ultramicrosurgical lymphaticovenular anastomoses (red arrow) has been performed between the 0.15 mm venule and the 0.15 mm lymphatic vessel. 2 end-to-end ultramicrosurgical lymphaticovenular anastomoses (blue arrows) have been performed between the 0.2 mm venule and the 0.35 mm lymphatic vessel.
280
Correspondence and communications
Figure 2 82 year old patient having a left Campisi clinical stage III breast cancer-related lymphedema. She was treated by 3 ultramicrosurgical lymphaticovenular anastomoses. (a): preoperative view. The mean circumferential excess rate was 14.7%. (b): postoperative view 2 years after surgery. The average circumferential differential reduction rate was 8.6%. The average volume differential reduction rate was 16.2%.
Conflict of interest None.
References 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. Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol 2005;10: 304e10. 3. Yap YL, Lim J, Shim TWH, Naidu S, Ong WC, Lim TC. Patent blue dye in lymphaticovenular anastomosis. Ann Ac Med 2009;38(8):704e6. 4. Ayestaray B, Bekara F, Andreoletti JB. Patent blue-enhanced lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2013;66:382e9. 5. Zhang HM, Yan YP, Sun GC, Hum HX, Liu ZF, Feng YJ. Cutaneous blood vessels in scent pigs. Plast Reconstr Surg 2000; 106(7):1555e65.
Benoit Ayestaray Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France Breast Center, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France E-mail address: [email protected] Jacques Chapiro Breast Center, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France
Didier Salvan Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, 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.2013.07.029
A simple and effective all-inside repair for FDP in zone 1 Dear Sir, Huq et al. have presented a beautifully-illustrated review of zone 1 FDP repair techniques, but have omitted to mention the more simple adaptation of the Sood technique where the suture is passed through the FDP tendon, and the ends simply tied over the tip of the distal phalanx (rather than using a drill-hole, as illustrated).1 Due to its slightly roughened surface and attachments to the palmar skin, I have never experienced the suture slipping off volarly. The knot can be tender if tied at the tip of the finger under the fish mouth incision, so I prefer to pass the suture back to the base of the distal phalanx, and tie the knot adjacent to
279
Ultramicrosurgical lymphaticovenular anastomosis using intradermal venules as recipient vessels
Switzerland). 1 end-to-end LVA was performed between the 0.15 mm venule and the 0.15 mm lymphatic vessel. 2 endto-end LVAs were performed between the 0.2 mm venule and the 0.35 mm lymphatic vessel (Figure 1(b), Video). The following is the supplementary video related to this article:
Dear Sir, Lymphaticovenular anastomoses (LVAs) have become a widespread method to treat chronic lymphedema. The concept of supermicrosurgery was introduced with the advance in microsurgical sutures of lymphatic vessels, which caliber is usually included between 0.3 and 0.8 mm.1,2 However, it is sometimes possible that no subdermal venule is adjacent to lymphatic vessels, leading supermicrosurgical LVAs impossible. We report a case of a 82 year old patient having a worsening Campisi clinical stage III lymphedema of the left upper limb. She did not wear daily elastic stocking and bandage, and stopped lymph drainage. The duration of her lymphedema was 8 years. The mean circumferential excess rate was 14.7%. She was treated by patent-blue enhanced lymphaticovenular anastomoses under local anesthesia.3,4 The caliber of subdermal vessels was measured with a professional scaled ruler (Shinwa Sokutei Co., Ltd., Sapporo Eigyosho, Japan). Superficial lymphatic vessels, which caliber was 0.35 mm and 0.15 mm, were dissected at the anteromedial part of her forearm (Figure 1(a), Video). No adjacent subdermal venule was found at the operative site. Two intradermal venules were dissected into the dermis, above these lymphatic vessels (Figure 1(a), Video). The first venule was 0.15 mm. The second venule was 0.2 mm. Ultramicrosurgical LVAs (using < 0.3 mm vessels) were performed with Ultrafine Microsurgical instruments (Medicon and Co., Tuttlingen, Germany), and 12-0 nylon monofilament on a 50 mm 3/8 needle (S&T, S&T AG, Neuhausen,
Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.bjps.2013.07.029. 2 years after surgery, the average circumferential differential reduction rate was 8.6%. The average volume differential reduction rate was 16.2% (Figure 2). The reduction of the pinch test at the forearm was 6 mm. Soft tissues were softer, the pinch test was thinner, and the subjective skin sensibility was improved. This clinical case proves the interest of intradermal venules to perform LVAs without necessity of changing the incision site. Anatomically, intradermal venules are distributed in a large network based on the dermal vascular plexus (DVP).5 One anatomical particularity is that they are completely independent of dermal arteries. Their diameter is inferior to the caliber of functional lymphatic vessels. It is usually included between 0.05 and 0.25 mm. The concept of vascular ultramicrosurgery can be defined as microanastomosis of vessels which caliber is strictly inferior to 0.3 mm. In this report, intradermal venules appear to be clinically valuable to perform ultramicrosurgical LVAs, and present as a salvage solution, when no subdermal venule is adjacent to lymphatic vessels.
EBM level Level V.
Disclosure None.
Figure 1 (a) Intraoperative view: one intradermal venule (red arrow) is visualized through the dermis. Two patent blue-enhanced lymphatic vessels of 0.35 mm (yellow star) and 0.15 mm (blue star) have been dissected. (b) Intraoperative view: 1 end-to-end ultramicrosurgical lymphaticovenular anastomoses (red arrow) has been performed between the 0.15 mm venule and the 0.15 mm lymphatic vessel. 2 end-to-end ultramicrosurgical lymphaticovenular anastomoses (blue arrows) have been performed between the 0.2 mm venule and the 0.35 mm lymphatic vessel.
280
Correspondence and communications
Figure 2 82 year old patient having a left Campisi clinical stage III breast cancer-related lymphedema. She was treated by 3 ultramicrosurgical lymphaticovenular anastomoses. (a): preoperative view. The mean circumferential excess rate was 14.7%. (b): postoperative view 2 years after surgery. The average circumferential differential reduction rate was 8.6%. The average volume differential reduction rate was 16.2%.
Conflict of interest None.
References 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. Nagase T, Gonda K, Inoue K, et al. Treatment of lymphedema with lymphaticovenular anastomoses. Int J Clin Oncol 2005;10: 304e10. 3. Yap YL, Lim J, Shim TWH, Naidu S, Ong WC, Lim TC. Patent blue dye in lymphaticovenular anastomosis. Ann Ac Med 2009;38(8):704e6. 4. Ayestaray B, Bekara F, Andreoletti JB. Patent blue-enhanced lymphaticovenular anastomosis. J Plast Reconstr Aesthet Surg 2013;66:382e9. 5. Zhang HM, Yan YP, Sun GC, Hum HX, Liu ZF, Feng YJ. Cutaneous blood vessels in scent pigs. Plast Reconstr Surg 2000; 106(7):1555e65.
Benoit Ayestaray Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France Breast Center, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France E-mail address: [email protected] Jacques Chapiro Breast Center, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, France
Didier Salvan Department of Plastic and Reconstructive Surgery, Sud Francilien Hospital, University Paris Sud XI, 116, Bd Jean Jaure`s, 91106 Corbeil-Essonnes, 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.2013.07.029
A simple and effective all-inside repair for FDP in zone 1 Dear Sir, Huq et al. have presented a beautifully-illustrated review of zone 1 FDP repair techniques, but have omitted to mention the more simple adaptation of the Sood technique where the suture is passed through the FDP tendon, and the ends simply tied over the tip of the distal phalanx (rather than using a drill-hole, as illustrated).1 Due to its slightly roughened surface and attachments to the palmar skin, I have never experienced the suture slipping off volarly. The knot can be tender if tied at the tip of the finger under the fish mouth incision, so I prefer to pass the suture back to the base of the distal phalanx, and tie the knot adjacent to