In most cases, lymphedema develops after surgery for breast cancer, uterine cancer and other cancers, and manifests as swelling of the upper or lower limbs. Conservative therapy for peripheral lymphedema is known as a complex decongestive physiotherapy (CDP), which involves a two-stage treatment program. The first phase consists of manual lymph drainage, range of motion exercise, skin care and compression typically applied with mufti-layered bandage wrapping. CDP is performed exclusively on an inpatient basis in specialized hospitals. The second phase aims to conserve and optimize the results obtained in Phase 1. This phase consists of compression by a low-stretch elastic stocking or sleeve, skin care, exercise and repeated self-induced lymph drainage as needed. These medical treatments can produce sufficient effects even if performed on an outpatient basis. Conservative therapy is extremely effective in reducing the circumference below the knee or elbow. A surgical procedure may be indicated when there is inadequate response to conservative therapy.
We demonstrate the physiological significance of rhythmical spontaneous contractions of collecting lymph vessels with special reference to the pathogenesis of tumor-mediated lymph edema. These spontaneous contractions play pivotal roles in regulating active lymph transport and controlling lymph formation by changing the pacemaker sites of the contractions and contractile patterns of lymphangions. The contractions also work physiologically under specific environment of lower oxygen tension in lymph (25 ∼ 40 mmHg), being another characteristic property in the lymphatic system. Chemical substances released from malignant tumor cells are also shown to produce a significant reduction of the spontaneous contractions through generation of endogenous nitric oxide and activation of ATP-dependent K+ channel. Finally, we discuss the pathophysiological significance of tumor-released chemical substance-dependent lymph edema in the tumor microcirculation.
Five consecutive cases of upper limb lymphedema treated by microsurgical lymphaticovenous implantation (MLVI) combined with compression therapy between February 2007 and July 2008 are presented in this article. Compression therapy was performed both before MLVI and after MLVI, and the circumferences of the affected limb were measured at 4 points: 3 cm distal and proximal to the wrist and 5 cm distal and proximal to the elbow. Preoperative assessment of the affected limb was performed by the average enlargement of edema circumference (AEEC), comparing the lymphedematous limb and normal limb circumferences. Objective improvement was analyzed by the percent reduction of edema circumference (%REC) at two levels in the lymphedema limb. With average follow-up of 10 months, 1 patient demonstrated excellent results with %REC > 50% at both the distal and proximal sites of the treated limb, and 4 patients demonstrated good results with %REC > 50% at the distal site of the treated limb.
Lymphedema of the lower extremities may develop following surgical resection of malignant tumors and intrapelvic lymph node dissection. We performed primary intrapelvic lymphaticovenular anastomosis (PILA) to prevent postoperative lymphedema in the lower extremities. The procedures were conducted in patients with cancer of the uterine body, who underwent total hystero-oophoretomy, together with intrapelvic and para-aortic lymph node dissection. The afferent lymphatics entering suprainguinal lymph nodes were end-to-end anastomosed with branches of the deep inferior epigastric veins. The procedure was performed in 8 patients aged between 35 and 61 years. We performed complete PILA procedures in 7 patients. However, there was one case of right PILA only and one case of left PILA only. The time required to construct PILA ranged from 100 to 200 minutes. There has not been any patient developing postoperative lymphangitis in this series. The follow-up period ranged from 66 to 52 months after surgery. Three patients showed mild lymphedema, two patients just after surgery, and one patient 50 months after surgery. None of the other patients has shown any signs of lymphedema on follow-up to date. PILA following lymph node dissection may be useful for the prevention of lymphedema in the lower extremities.
There are two categories of physical rehabilitation for facial paralysis. One is peripheral rehabilitation for facial paralysis due to Bell's palsy or end-to-end facial anastomosis. The goal is to prevent or minimize aberrant regeneration. Clinical synkinesis would eventually develop after 4 months provided degeneration is neurotmesis, which could be confirmed by an electroneurogram less than 40% 2 weeks after onset. Conventional voluntary muscle strengthening exercises accentuate regeneration of fibers in not only neuropraxia and axonotmesis but also neurotmesis. To avoid synkinesis or contracture, frequent stretching is indispensable especially during the first 3 months. Stretching massage is more effective than muscle strengthening exercise for patients with complete facial paralysis. However, the approach is completely different with strong voluntary symmetrical exercises synchronized with using tongue. The facial cortex of the involved face needs to be reorganized after facial nerve reconstruction. The goal is to reorganize the hypoglossal area into facial motor cortex. Critical factors are use-dependent plasticity, earlier intervention and feedback result or reward. To reanimate the involved face with cross-face nerve graft, activation of the contralateral facial cortex dominating the involved face by means of uncrossed facial fibers and graft is needed. Peripheral reconstruction surgery requires central rehabilitation to reorganize facial cortex.
The usefulness of postoperative rehabilitation was evaluated for patients undergoing surgical treatment using the facial nerve on the healthy side as a motor source. The rehabilitation regimen consisted of self-training. The purpose of rehabilitation is to increase muscle contractility and eliminate the pathological synkinesis. Patients treated by vascularized muscle transplantation showed progressive improvement of muscle contractility for more than 3 years postoperatively and became able to move the transplanted muscle without accompanying action of the face on the healthy side. However, patients treated by cross-face nerve grafting could not get rid of the pathological synkinesis that caused involuntary simultaneous eye closure when smiling. It seemed that the relation between the dividing point of the nerve branches and nerve suture site would influence the efficacy of rehabilitation. It is recommended that patients continue self-training of the muscle at least for more than three years, because muscle contractility retains the ability to recover for a rather long time.
We perform neurovascular free muscle transfer for smile reconstruction in the treatment of established facial paralysis. Some surgical methods have previously been reported for neurovascular free muscle transfer, but we describe herein a one-stage latissimus dorsi muscle transplantation. The aim of reconstruction by neurovascular free muscle transfer is that the paralyzed side will achieve dynamic movement synchronized with the non-paralyzed side of the face. To achieve this aim: 1) the transferred muscle must contract smoothly and sufficiently; and 2) movement of the transferred muscle must reflect the formation of an expression well. To achieve the former goal, we perform rehabilitation for two years postoperatively. In particular it is important that the patient performs rehabilitation using a mirror in order to receive visual feedback while making an expression. To achieve the latter goal, we perform revisional surgery for problems with the neurovascular free muscle transfer arising more than two years postoperatively. Neurovascular free muscle transfer is now a standard procedure for dynamic smile reconstruction in patients with established facial paralysis. As postoperative treatment, it is important to perform rehabilitation for two years postoperatively. Furthermore, a revisional operation is effective. Good results have been obtained by treatment based on “ total facial reconstruction ”.
Weakness, hypertonicity, loss of isolated control and/or synkinetic movement of the facial mimetic muscle are common sequelae after facial palsy, unlike disruption of nerve continuity as in Bell's palsy or Hunt's syndrome. Here we describe a surgical procedure and postsurgical rehabilitation for the treatment of such sequelae. The surgical procedure comprises facial and hypoglossal nerve cross-linking that connects the nerves by an interpositional nerve graft with end-to-side anastomosis. For postsurgical physical rehabilitation, patients are instructed in the following techniques for facial neuromuscular retraining: 1) to practice isolated facial motion in front of a mirror (mirror-biofeedback technique); 2) to avoid gross voluntary movement both during practice and in daily life; and 3) to frequently massage and stretch the affected facial muscle. Between December 2005 and May 2008, twenty patients with sequelae after facial palsy were treated by our rehabilitation technique. Sixteen patients showed improvement in abnormal facial movement, while four did not. None of the patients developed facial synkinesis associated with tongue motion. Our surgical procedure and postsurgical rehabilitation exercises are alternative techniques for the sequelae of facial palsy.
By infusing the femoral artery in a fresh chicken leg with dyed water after forming a microvascular anastomosis in that artery, we can detect failures of false sutures due to dyed-water leakage, vascular distortion and the formation of pits on the blood vessel wall. Using a chicken leg, a surgical trainee can also practice microvascular anastomosis at multiple positions on the artery within a short time. Therefore, this model is useful for a novice trainee to practice microvascular surgical techniques.
Replantation of the digits amputated at the level of distal phalanx is difficult owing to the small diameters of the digital arteries and veins that are unsuitable for anastomosis. However, in patients with distal phalangeal amputation, achieving replantation of the fingertips is essential because it facilitates the good functioning of the uninjured proximal interphalangeal (PIP) joints. Hence, whenever possible, we performed distal phalangeal replantations in patients. Materials and methods: We replanted 40 digits that had amputated at the level of distal phalanx at our center between 2005 and 2008. We assessed the amputation levels (Ishikawa's classification) and amputation types (sharp, blunt, crush, and avulsion), the numbers of anastomosed veins, and whether vein grafting or re-operation was required or not in these patients. We determined their survival rate according to the amputation subzone levels, amputation types, and numbers of anastomosed veins. After the operation, we examined the color of the patients' fingers to determine whether they showed congestion. Results and discussion: The survival rate of the patients was 82.5%. The survival rate was the lowest in the patients who had undergone replantation in subzone III, but the difference was not statistically significant. The survival rate of patients who underwent replantation for blunt-type amputations was significantly higher and that of patients who underwent replantation for avulsion-type amputations was significantly lower. There was no significant difference among the groups according to the numbers of anastomosed veins (0-3). However, all the 6 digits in which vein anastomosis could not be achieved showed congestion immediately after the operation, and 4 of the 22 digits in which anastomosis could be achieved only in one vein showed congestion postoperatively. The survival rate of the patients who needed vein grafting was 57.1%. Re-operation was required in 5 digits, and all these cases survived after the re-operation. Our results suggest that venous anastomosis after distal phalangeal amputation is important, and surgeons should attempt to perfom venous anastomosis to avoid congestion of the replantated fingertips. Obstructed beins or arteries should be re-anastomosed immediately after change in the finger tip color is noted.
The surgical technique and results of treating post-traumatic radio-ulnar ankylosis in three patients are reviewed. In all cases, the treatment was excision of the cross-union and interposition of a pedicled vascularized adiposal graft, which included a couple of veins. The functional results were excellent, and there was no evidence of the regrowth of the synostosis in any patient after 13.7 months of follow-up.
A 54-year-old man underwent surgical treatment for mesopharyngeal cancer. He had a history of prostate cancer and underwent laparoscopically assisted total prostatectomy via a lower abdominal midline incision. The mesopharyngeal cancer was treated by bilateral neck dissection and total glossectomy with preservation of the larynx. To maintain eating function, swallowing function and larynx preservation after total glossectomy, reconstruction was performed using a rectus abdominis musculocutaneous flap. While exposing the deep inferior epigastric artery and vein during elevation of the rectus abdominis musculocutaneous flap, a laparoscopic examination showed severe stenosis in part of the vein due to scarring. As a supplementary vessel, the superior epigastric vein was isolated and elevated together with the flap. After suturing the flap over the tissue defect, the deep inferior epigastric artery was anastomosed to the superior thyroid artery, and the deep inferior epigastric vein to the internal jugular vein. When the flap was reperfused, congestion was observed in the flap. By anastomosing the superior epigastric vein to the contralateral facial vein, congestion of the flap was markedly improved. When congestion is predicted in the rectus abdominis musculocutaneous flap, super drainage via the superior epigastric vein is a useful method to improve congestion.
We presented a 5-year-old girl who underwent replantation of the left upper arm. Her left arm was severed by a tram at a factory where her mother was employed. The injury was a local crush amputation. Immediate replantation surgery was performed under general anesthesia. The humerus had a double fracture of the shaft. It was shortened 4 cm and fixed with intramedullar Kirschner wires. We sutured the brachial artery, vein and subcutaneous vein with an interpositional vein graft. The ischemia time was about 6 hours. The medial, ulnar, and radial nerves were sutured in an end-to-end fashion. Six months after surgery, functional recovery had obtained grade III of Chen's criteria. One year after surgery, she had achieved grade II recovery on Chen's criteria without additional surgery.The reasons this patient achieved a relatively good outcome within one year might be the young age of the patient and reduction of the misdirection rate by end-to-end suture of the severed main nerve trunks without nerve grafting.
De Quervain's disease can be treated by conservative therapies such as intra-sheath triamcinolone injections and surgical procedures. Superficial radial nerve injury occurring after injection or surgery is one of most serious complications influencing patient satisfaction. Furthermore, it is difficult to treat such a lesion. We describe the usefulness of a radial artery perforator-based adipose flap in a 29-year-old female patient with adherent superficial radial nerve injury after surgery for de Quervain's disease. After undergoing surgical release of the first compartment, the patient complained of pain and paresthesia of her thumb. Surgical findings demonstrated evidence of superficial radial nerve injury with perineural fibrosis. Following neurolysis, a radial artery perforator-based adipose flap was used to envelop the nerve. Postoperatively, the patient reported complete relief of the symptoms. The superficial nerves are considered vascular relays due to the associated neurocutaneous arteries. Therefore, we consider it useful to wrap the adherent nerve with a perforator-based adipose flap after performing neurolysis.