290
Correspondence and communications
demonstrated. In that case, we conclude that the simplest and cheapest effective solution for this common procedure should always be sought.
Conflict of interest statement Neither author has any conflict of interest to declare.
Funding None.
Ethical approval Not required.
References 1. Joyce CW, Joyce KM, Mahon N, et al. A novel barbed suture tie-over dressings for skin grafts: a comparison with traditional techniques. J Plast Reconst Aesthet Surg 2014;67: 1237e41. 2. Seymour FK, Giele HP. Tie-overs under pressure. Br J Plast Surg 2003;56:494e7.
Ciara McGoldrick StR Plastic Surgery, Ulster Hospital, Dundonald, Upper Newtownards Road, Belfast BT16 1RH, UK E-mail address: [email protected] Derek Gordon Ulster Hospital, Dundonald, Upper Newtownards Road, Belfast BT16 1RH, UK ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.052
Never fear the venouslymphatic coupler is here!
Figure 1
Lymphatic placement on coupler complete.
1986. Subsequently, lymphoedema developed in the right arm. She had an implant reconstruction in 2000 and had significant capsular contracture revised in 2012 with a pedicled latissimus dorsi flap and implant. This resulted in some improvement of the lymphoedema of the hand but she still had residual lymphoedema of the rest of the arm predominantly around the forearm. She was referred to our service for assessment where reversible swelling was noted. The ICG with PDE indicated possible targets in the dorsal hand and palm, so 2 LVAs were planned. On the day of surgery the patient complained of an incidental lesion at the elbow so an opportunistic excisional biopsy was planned. The biopsy scar was extended after local injection of Patent V dye and large lymphatics of around 1 mm were noted coursing around the lateral elbow over anconeus. There was a paucity of recipient veins so the cephalic vein (2 mm) was mobilised and turned down into the wound. As the lymphatic vessel was 1 mm, the 1 mm coupler was used to good effect with blue dye demonstrated going into the recipient vein (Figures 1 and 2). The flow was also confirmed on ICG. This is the first reported use of the coupler in lymphatic surgery and may be an option when larger lymphatic vessels are seen. Another similar case has been carried out by the third author at The Mayo Clinic. The use of the coupler enables the anastomosis of small lymphatics to vessels that
Dear Sir, The venous coupler is a well described, efficient and versatile device that has been taken up widely across the microvascular world.1 The coupler has benefitted autologous breast reconstruction in particular by reducing theatre times and improving patency rates due to the lack of intraluminal suture material. Supramicrosurgery has been developed to deal with the demands of lymphatic venous anastomoses where typically anastomoses require 11/0 or 12/0 sutures.2 However, this may not always be the case. A 53 year old patient suffered right sided breast cancer requiring mastectomy and radiotherapy to the chest wall and supraclavicular fossa and brachytherapy in
Figure 2
Coupled LVA.
Correspondence and communications otherwise may prove to be a difficult technique. This technique may aid the field of lymphovascular anastomosis and with the future development of smaller couplers may prove invaluable to the field of lymphoedema treatment.
Conflict of interest None.
Funding None.
291 2. Koshima Isao, Narushima Mitsunaga, Yamamoto Yusuke, Mihara Makoto, Iida Takuya. Recent advancement on surgical treatments for lymphedema. Ann Vasc Dis 2012;5(4):409e15. http://dx.doi.org/10.3400/avd.ra.12.00080. Published online 2012 November 30.
Pundrique Sharma Hrsikesa Sharma Michel St Cyr Mat Griffiths St Andrew’s Centre for Plastic Surgery and Burns, United Kingdom The Mayo Clinic, USA E-mail address: [email protected]
References 1. Sullivan SK, Dellacroce F, Allen R. Management of significant venous discrepancy with microvascular venous coupler. J Reconstr Microsurg 2003 Aug;19(6):377e80. 0743-684X.
ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.013
Correspondence and communications
demonstrated. In that case, we conclude that the simplest and cheapest effective solution for this common procedure should always be sought.
Conflict of interest statement Neither author has any conflict of interest to declare.
Funding None.
Ethical approval Not required.
References 1. Joyce CW, Joyce KM, Mahon N, et al. A novel barbed suture tie-over dressings for skin grafts: a comparison with traditional techniques. J Plast Reconst Aesthet Surg 2014;67: 1237e41. 2. Seymour FK, Giele HP. Tie-overs under pressure. Br J Plast Surg 2003;56:494e7.
Ciara McGoldrick StR Plastic Surgery, Ulster Hospital, Dundonald, Upper Newtownards Road, Belfast BT16 1RH, UK E-mail address: [email protected] Derek Gordon Ulster Hospital, Dundonald, Upper Newtownards Road, Belfast BT16 1RH, UK ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.09.052
Never fear the venouslymphatic coupler is here!
Figure 1
Lymphatic placement on coupler complete.
1986. Subsequently, lymphoedema developed in the right arm. She had an implant reconstruction in 2000 and had significant capsular contracture revised in 2012 with a pedicled latissimus dorsi flap and implant. This resulted in some improvement of the lymphoedema of the hand but she still had residual lymphoedema of the rest of the arm predominantly around the forearm. She was referred to our service for assessment where reversible swelling was noted. The ICG with PDE indicated possible targets in the dorsal hand and palm, so 2 LVAs were planned. On the day of surgery the patient complained of an incidental lesion at the elbow so an opportunistic excisional biopsy was planned. The biopsy scar was extended after local injection of Patent V dye and large lymphatics of around 1 mm were noted coursing around the lateral elbow over anconeus. There was a paucity of recipient veins so the cephalic vein (2 mm) was mobilised and turned down into the wound. As the lymphatic vessel was 1 mm, the 1 mm coupler was used to good effect with blue dye demonstrated going into the recipient vein (Figures 1 and 2). The flow was also confirmed on ICG. This is the first reported use of the coupler in lymphatic surgery and may be an option when larger lymphatic vessels are seen. Another similar case has been carried out by the third author at The Mayo Clinic. The use of the coupler enables the anastomosis of small lymphatics to vessels that
Dear Sir, The venous coupler is a well described, efficient and versatile device that has been taken up widely across the microvascular world.1 The coupler has benefitted autologous breast reconstruction in particular by reducing theatre times and improving patency rates due to the lack of intraluminal suture material. Supramicrosurgery has been developed to deal with the demands of lymphatic venous anastomoses where typically anastomoses require 11/0 or 12/0 sutures.2 However, this may not always be the case. A 53 year old patient suffered right sided breast cancer requiring mastectomy and radiotherapy to the chest wall and supraclavicular fossa and brachytherapy in
Figure 2
Coupled LVA.
Correspondence and communications otherwise may prove to be a difficult technique. This technique may aid the field of lymphovascular anastomosis and with the future development of smaller couplers may prove invaluable to the field of lymphoedema treatment.
Conflict of interest None.
Funding None.
291 2. Koshima Isao, Narushima Mitsunaga, Yamamoto Yusuke, Mihara Makoto, Iida Takuya. Recent advancement on surgical treatments for lymphedema. Ann Vasc Dis 2012;5(4):409e15. http://dx.doi.org/10.3400/avd.ra.12.00080. Published online 2012 November 30.
Pundrique Sharma Hrsikesa Sharma Michel St Cyr Mat Griffiths St Andrew’s Centre for Plastic Surgery and Burns, United Kingdom The Mayo Clinic, USA E-mail address: [email protected]
References 1. Sullivan SK, Dellacroce F, Allen R. Management of significant venous discrepancy with microvascular venous coupler. J Reconstr Microsurg 2003 Aug;19(6):377e80. 0743-684X.
ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.013
