Although lymphedema in the extremities is a troublesome adverse effect following radical resection of various cancers, conventional therapies for lymphedema are not always satisfactory, and new breakthroughs are anticipated. With the introduction of supermicrosurgical techniques for the anastomosis of blood or lymphatic vessels less than 0.8 mm in diameter, we have developed a novel method of lymphaticovenular anastomosis for the treatment of primary as well as secondary lymphedema in the extremities. Here, we review the pathophysiological aspects of lymphedema, emphasizing the importance of smooth-muscle cell function in the affected lymphatic walls. We then describe the theoretical basis and detailed operative techniques of our lymphaticovenular anastomoses. Although technically demanding, especially for beginners, we believe that this method will become a new clinical standard for the treatment of lymphedema in the near future.
Three cases in which island medial plantar artery perforator flaps were successfully transferred for coverage of the plantar defects are described. This perforator flap is different from the medial plantar flap based on the medial plantar artery. The flap has no fascial component and is nourished only with the perforator of the medial plantar vessel. Therefore, transection of the medial plantar artery is usually unnecessary. This flap can cover defects on the forefoot and heel without transaction of the medial plantar system. The advantages of this flap are no need for deep or long dissection for the medial plantar vessel, no exposure of the plantar sensory nerve, a short time for flap elevation, minimal donor-site morbidity, relatively large flap survival, and no damage of both the posterior tibial and medial plantar neurovascular systems.
We present a 64-year-old woman who had a congenital defect of the nasal septal cartilage and vomeral bone. She noticed her nasal tip was collapsed approximately 2 months before consultation. Computed tomography showed the absence of cartilaginous septum and vomeral bone, and radiograph showed a depression in the anterior nasal floor and hypoplasia of anterior nasal spine. She had no history of maxillofacial trauma, disease, or surgery in the midface. Fiberendoscopic examination of nasal cavity showed normal mucosa without signs of chronic inflammatory diseases such as Wegener's granulomatosis. Her intelligence was normal, and no anomaly was observed in the cranial region. Blood examination showed negative including serologic tests for syphilis. No other systemic findings were found, and none of her relatives were similarly afflicted. From these findings, we concluded that the patient did not have Binder's syndrome (or she has, at least, a new variant of Binder's syndrome). Rhinoplasty with cantilever costal cartilaginous graft was performed. The "hook-shaped part" was carved on the dorsal graft, which served to reduce the collapsed lateral cartilage. Eight months postoperatively, the flattened nose was well corrected with acceptable projection.
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