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Abstract: Venous Anastomosis to Control Lymph Flow for Lymphatic Malformations

METHODS: With the same perforator anatomy of fibula flap5 and slight modification of harvest technique of fibula flap, the peroneal flap could be harvested within 1 to 2 hours. Between 1996 and 2015, 246 peroneal flaps and 114 ALT flaps were used in the head and neck reconstruction by the senior author (Dr. Yang). A variety of applications to different types of defects will be demonstrated to show its versatility. We retrospectively reviewed the medical records, looking for all the perioperative complications. The perioperative complication rate of ALT flap was used as a comparison group to validate the viability of the peroneal flap. Stata 9.1 software (StataCorp, Inc., Texas, USA) was used for statistical analysis. Fisher’s exact test was conducted to compare the two groups. A p value less than 0.05 was considered statistically significant.

flap could leave poorly-hidden scar on the forearm and sometimes cause cold intolerance over the hand. 1 In our institution, peroneal flap has been the workhorse flap for the soft tissue defect in head and neck reconstruction. [2][3][4] The goal of this study is to present the peroneal flap as a feasible option for head and neck reconstruction.

METHODS:
With the same perforator anatomy of fibula flap 5 and slight modification of harvest technique of fibula flap, the peroneal flap could be harvested within 1 to 2 hours. Between 1996 and 2015, 246 peroneal flaps and 114 ALT flaps were used in the head and neck reconstruction by the senior author (Dr. Yang). A variety of applications to different types of defects will be demonstrated to show its versatility. We retrospectively reviewed the medical records, looking for all the perioperative complications. The perioperative complication rate of ALT flap was used as a comparison group to validate the viability of the peroneal flap. Stata 9.1 software (StataCorp, Inc., Texas, USA) was used for statistical analysis. Fisher's exact test was conducted to compare the two groups. A p value less than 0.05 was considered statistically significant.

RESULTS:
Compared to radial forearm flap, none of our patients after peroneal flap harvest complaint about cold intolerance over the foot, and skin grafted flap donor sites were shifted to less noticeable lower legs. Compared to ALT flap, because peroneal flap was thinner and more pliable, in some conditions, it was more suitable for head and neck reconstruction. For example, an aesthetically pleasing and saliva-leakage preventing neo-commissure could be easily created 4 . Statistically speaking, in our series, there is no difference between ALT and peroneal flap in terms of perioperative complications rates (p= 0.18).
CONCLUSION: Due to its easy learning curve, better-hidden scar than radial forearm flap, thinner skin paddle than ALT flap, and comparable complication rates with ALT flap, peroneal flap should be considered a feasible option for the head and neck reconstruction.

INTRODUCTION:
There are several lymphatic diseases that could be treated surgically. Lymphatic venous anastomosis (LVA) was developed to improve lymphedema. On the other hand, in children settings, the majority of lymph diseases are not lymphedema, but lymphangioma or also called lymphatic malformations (LM). This LM especially micro-cystic type LM (mLM) had been challenging to treat because the conventional therapy had been limited efficacy and highly cause complications. To change the strategy, focusing on the lymph flow was the key for this disease. Thus we modified and analysed LVA to improve mLM of children.

METHODS:
We indicated 14 sequential cases of mLM patients who appeared to our clinic from July 2015 to June 2016, 10 males and 4 females, between 0 to 12 (mean 4) year-old. All cases underwent indocyanine green (ICG) lymphangiography and modified LVA under general anesthesia. Single surgeon (presenting author) performed all surgeries. Depend on the ICG findings of flow pattern we classified anastomosis manners into 2 groups; 1, LVA to decrease the in-flow and 2, increase the out-flow directly from the cysts.

RESULTS:
In all cases successful assessment with ICG were possible. 11 out of 14 (79%) cases were improved their situations such as size decrease, vesicle disappearance, or prevent following functional loss. Only one case increased vesicles on the surgical site. No complications such as allergy reactions, lymphorrhea, functional loss, surgical site infections or post-operative bleeding were observed.

CONCLUSION:
We applied ICG and modified LVA for mLM patients and found they are effective. This flow oriented surgical strategy with ICG and LVA for LM was very unique. To our best knowledge, this is the first report that shows the effectiveness of ICG and of LVA on LM. mLM were considered that related to the obstruction of lymph flow proximally. Conventional surgeries were limited, so this surgical strategy could be a break-through for this challenging disease. And also ICG and LVA could spread their indications to a new field.
The limitation of this study was the short time follow-up period after the surgery, so more cases should be indicated.