Plastic and Reconstructive Surgery • June 2014 the success rate of lymphaticovenular anastomoses deteriorates.4 It is not difficult for a surgeon experienced in performing lymphatic supermicrosurgery to find a lymphatic vessel in obstructive lymphedema cases, because the location of lymphatic vessels suitable for lymphaticovenular anastomosis is anatomically invariable; lymphatic vessels can be found along the greater saphenous vein or the cephalic vein by means of a 2- to 3-cm skin incision. However, it is difficult to predict the condition of lymphatic vessels (whether the vessel is suitable for lymphaticovenular anastomosis or not); thus, differentiation of dermal backflow pattern is very helpful for predicting the condition of lymphatic vessels—linear, splash patterns are good and the stardust pattern is acceptable, but the diffuse pattern is not appropriate for lymphaticovenular anastomosis.4 When a lymphedematous limb shows extensive diffuse pattern on indocyanine green lymphography, vascularized lymph node transfer is better indicated than lymphaticovenular anastomosis. To differentiate dermal backflow patterns, indocyanine green lymphographic findings should be evaluated not at an early transient phase but at a late plateau phase (2 or more hours after injection)2,3,5 (Fig. 2). Thus, we perform indocyanine green lymphography as follows: an examinee is kept still for 5 minutes after indocyanine green injection, and indocyanine green velocity measurement and lymphatic mapping are performed (early phase); then, the examinee is allowed to move freely, and dermal backflow stage is determined 2 or more hours later (late phase).5 This dual-phase or dynamic indocyanine green lymphography allows not only preoperative lymph mapping but also evaluation of lymph pump function (indocyanine green velocity) and lymph circulation (dermal backflow stage) by one injection. DOI: 10.1097/PRS.0000000000000189
Takumi Yamamoto, M.D. Isao Koshima, M.D. Department of Plastic and Reconstructive Surgery Graduate School of Medicine University of Tokyo Tokyo, Japan Correspondence to Dr. Yamamoto Department of Plastic and Reconstructive Surgery University of Tokyo 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132: 1305–1314.
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2. Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128:314e–321e. 3. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine greenenhanced lymphography for upper extremity lymphedema: A novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;128:941–947. 4. Yamamoto T, Yamamoto N, Narushima M, et al. Lymphaticovenular anastomosis with guidance of ICG lymphography. J Jpn Coll Angiol. 2012;52:327–331. 5. Yamamoto T, Narushima M, Yoshimatsu H, et al. Indocyanine green velocity: Lymph transportation capacity deterioration with progression of lymphedema. Ann Plast Surg. 2013;71:591–594.
Reply: A Prospective Analysis of 100 Consecutive Lymphovenous Bypass Cases for Treatment of Extremity Lymphedema Sir:
We would like to thank Drs. Yamamoto and Koshima for their insightful comments. We agree that what is critically important is to precisely identify functioning lymphatic vessels for lymphovenous bypass. We are aware that the lymphatic vessels do run along the great saphenous and cephalic vein; these are called the median or medial bundle.1 However, these lymphatic vessels are not always detected during indocyanine green lymphography, meaning that they are not always functional in certain lymphedema patients. We speculate that in these patients the associated lymph nodes or the proximal portion of the medial lymphatic bundle were excised or damaged during the axillary or inguinal dissection. Thus, just relying on our knowledge of lymphatic anatomy alone is not sufficient for identifying optimal lymphatic vessels for bypass. We have found that the best way to identify functioning lymphatic vessels for lymphovenous bypass is to perform indocyanine green fluorescence lymphography and mapping of the functioning lymphatic vessels just before surgery. As soon as the indocyanine green is injected, fluorescent images of the functioning lymphatic vessels can be visualized using a Hamamatsu Photodynamic Eye (Hamamatsu Photonics, Hamamatsu, Japan), and the mapping is performed on the skin surface immediately. As time passes, even after just 10 to 15 minutes, indocyanine green dye refluxes into the superficial and subdermal lymphatics of the limb, creating the various patterns of dermal backflow, as described by Drs. Yamamoto and Koshima. Once this occurs, the linear patterns of functioning lymphatic vessels often are no longer visible, as they are overshadowed by dermal backflow. We agree with Drs. Yamamoto and Koshima that the type of dermal backflow is important for staging, but we have found in our experience that the quality and the quantity of functioning lymphatic vessels identified by indocyanine green fluorescence lymphography just before surgery not only facilitate the operation
Volume 133, Number 6 • Letters but are among the key factors in determining the outcome following lymphovenous bypass. DOI: 10.1097/PRS.0000000000000209
David W. Chang, M.D. Section of Plastic and Reconstructive Surgery Department of Surgery Medicine and Biological Sciences The University of Chicago Chicago, Ill.
Hiroo Suami, M.D., Ph.D. Roman Skoracki, M.D. Department of Plastic Surgery The University of Texas M. D. Anderson Cancer Center Houston, Texas Correspondence to Dr. Chang Section of Plastic and Reconstructive Surgery Department of Surgery Medicine and Biological Sciences The University of Chicago 5841 South Maryland Avenue Room J641, MC 6035 Chicago, Ill. 60637 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
than the three other systems. These findings seem to be very interesting and are useful data clinicians can use to assess the performance of the available separation methods as the authors aimed. The most shocking result is the residual protease activity observed with the Multi Station, Cha-Station, and Lipokit, which averaged 5.1-, 13.0-, and 57-fold higher, respectively, than that observed with the Celution System. Seeing the Lipokit have a 57-fold higher residual enzyme level than the Celution System, I have to mention the “nonmaleficence” (do no harm) whereby physicians must refrain from providing ineffective treatments or acting with malice toward patients.2 I am curious whether all four manufacturers including the Lipokit agree with the process or the results of this experiment. In the case in which they do not agree with the results, it is wise that they show their own data and explain the discrepancy of the results. DOI: 10.1097/PRS.0000000000000188
Seong Kee Kim, M.D.
Dr. Kim’s Aesthetic Plastic Surgical Clinic 2F, Buyeong Building, 666-31 Sinsa-dong, Gangnam-gu Seoul 135-897, Republic of Korea [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
REFERENCE 1. Kubik S, Kretz O. Anatomy of the lymphatic system. In: Földi’s Textbook of Lymphology. Munich: Elsevier GmbH; 2006:1–149.
Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems Sir:
T
he following comments pertain to “Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems” by Aronowitz and Ellenhorn (Plast Reconstr Surg. 2013;132:932e–939e).1 In that article, the authors evaluated system process time, viable cell yield, composition, residual enzyme, and operating costs in four different cell separation systems. According to their analysis, the Celution System (Cytori Therapeutics, Inc., San Diego, Calif.) yielded the highest mean number of viable nucleated cells (2.41 × 105 cells/g) followed by the Multi Station (PNC International, Gyeonggi-do, Republic of Korea) (1.07 × 105 cells/g). The Lipokit (Medi-Khan, West Hollywood, Calif.) and Cha-Station (CHA Biotech, Kangnamgu, Republic of Korea) systems yielded fewer nucleated cells (0.35 × 105 cells/g and 0.05 × 105 cells/g, respectively). The Celution System also yielded significantly more endothelial cells, CD34/CD31 cells, and adiposederived stem cells (colony-forming unit-fibroblast)
REFERENCES 1. Aronowitz JA, Ellenhorn JD. Adipose stromal vascular fraction isolation: A head-to-head comparison of four commercial cell separation systems. Plast Reconstr Surg. 2013;132:932e–939e. 2. Pantilat S. Fast facts: Beneficence vs. nonmaleficence. Available at: http://missinglink.ucsf.edu/lm/ethics/content%20pages/ fast_fact_bene_nonmal.htm. Accessed December 4, 2013.
Reply: Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems Sir:
I appreciate the concerns expressed by Dr. Seong Kee Kim regarding the results of our recent study showing substantial differences in pluripotential cell yields and residual enzyme among between the four devices tested. A trained technician operated each device using the manufacturer-recommended protocol and the reported results have not been disputed. Dr. Kim is correct to raise the issue of residual enzyme levels in the separation product and it is certainly worthy of a brief discussion to clarify the issue. All efficient cell separation processes depend on some combination of Clostridia histolyticum–derived collagenases and a neutral protease to free progenitor cells from intercellular connecting proteins such
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Takumi Yamamoto, M.D. Isao Koshima, M.D. Department of Plastic and Reconstructive Surgery Graduate School of Medicine University of Tokyo Tokyo, Japan Correspondence to Dr. Yamamoto Department of Plastic and Reconstructive Surgery University of Tokyo 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Chang DW, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132: 1305–1314.
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2. Yamamoto T, Matsuda N, Doi K, et al. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128:314e–321e. 3. Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine greenenhanced lymphography for upper extremity lymphedema: A novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;128:941–947. 4. Yamamoto T, Yamamoto N, Narushima M, et al. Lymphaticovenular anastomosis with guidance of ICG lymphography. J Jpn Coll Angiol. 2012;52:327–331. 5. Yamamoto T, Narushima M, Yoshimatsu H, et al. Indocyanine green velocity: Lymph transportation capacity deterioration with progression of lymphedema. Ann Plast Surg. 2013;71:591–594.
Reply: A Prospective Analysis of 100 Consecutive Lymphovenous Bypass Cases for Treatment of Extremity Lymphedema Sir:
We would like to thank Drs. Yamamoto and Koshima for their insightful comments. We agree that what is critically important is to precisely identify functioning lymphatic vessels for lymphovenous bypass. We are aware that the lymphatic vessels do run along the great saphenous and cephalic vein; these are called the median or medial bundle.1 However, these lymphatic vessels are not always detected during indocyanine green lymphography, meaning that they are not always functional in certain lymphedema patients. We speculate that in these patients the associated lymph nodes or the proximal portion of the medial lymphatic bundle were excised or damaged during the axillary or inguinal dissection. Thus, just relying on our knowledge of lymphatic anatomy alone is not sufficient for identifying optimal lymphatic vessels for bypass. We have found that the best way to identify functioning lymphatic vessels for lymphovenous bypass is to perform indocyanine green fluorescence lymphography and mapping of the functioning lymphatic vessels just before surgery. As soon as the indocyanine green is injected, fluorescent images of the functioning lymphatic vessels can be visualized using a Hamamatsu Photodynamic Eye (Hamamatsu Photonics, Hamamatsu, Japan), and the mapping is performed on the skin surface immediately. As time passes, even after just 10 to 15 minutes, indocyanine green dye refluxes into the superficial and subdermal lymphatics of the limb, creating the various patterns of dermal backflow, as described by Drs. Yamamoto and Koshima. Once this occurs, the linear patterns of functioning lymphatic vessels often are no longer visible, as they are overshadowed by dermal backflow. We agree with Drs. Yamamoto and Koshima that the type of dermal backflow is important for staging, but we have found in our experience that the quality and the quantity of functioning lymphatic vessels identified by indocyanine green fluorescence lymphography just before surgery not only facilitate the operation
Volume 133, Number 6 • Letters but are among the key factors in determining the outcome following lymphovenous bypass. DOI: 10.1097/PRS.0000000000000209
David W. Chang, M.D. Section of Plastic and Reconstructive Surgery Department of Surgery Medicine and Biological Sciences The University of Chicago Chicago, Ill.
Hiroo Suami, M.D., Ph.D. Roman Skoracki, M.D. Department of Plastic Surgery The University of Texas M. D. Anderson Cancer Center Houston, Texas Correspondence to Dr. Chang Section of Plastic and Reconstructive Surgery Department of Surgery Medicine and Biological Sciences The University of Chicago 5841 South Maryland Avenue Room J641, MC 6035 Chicago, Ill. 60637 [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
than the three other systems. These findings seem to be very interesting and are useful data clinicians can use to assess the performance of the available separation methods as the authors aimed. The most shocking result is the residual protease activity observed with the Multi Station, Cha-Station, and Lipokit, which averaged 5.1-, 13.0-, and 57-fold higher, respectively, than that observed with the Celution System. Seeing the Lipokit have a 57-fold higher residual enzyme level than the Celution System, I have to mention the “nonmaleficence” (do no harm) whereby physicians must refrain from providing ineffective treatments or acting with malice toward patients.2 I am curious whether all four manufacturers including the Lipokit agree with the process or the results of this experiment. In the case in which they do not agree with the results, it is wise that they show their own data and explain the discrepancy of the results. DOI: 10.1097/PRS.0000000000000188
Seong Kee Kim, M.D.
Dr. Kim’s Aesthetic Plastic Surgical Clinic 2F, Buyeong Building, 666-31 Sinsa-dong, Gangnam-gu Seoul 135-897, Republic of Korea [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.
REFERENCE 1. Kubik S, Kretz O. Anatomy of the lymphatic system. In: Földi’s Textbook of Lymphology. Munich: Elsevier GmbH; 2006:1–149.
Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems Sir:
T
he following comments pertain to “Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems” by Aronowitz and Ellenhorn (Plast Reconstr Surg. 2013;132:932e–939e).1 In that article, the authors evaluated system process time, viable cell yield, composition, residual enzyme, and operating costs in four different cell separation systems. According to their analysis, the Celution System (Cytori Therapeutics, Inc., San Diego, Calif.) yielded the highest mean number of viable nucleated cells (2.41 × 105 cells/g) followed by the Multi Station (PNC International, Gyeonggi-do, Republic of Korea) (1.07 × 105 cells/g). The Lipokit (Medi-Khan, West Hollywood, Calif.) and Cha-Station (CHA Biotech, Kangnamgu, Republic of Korea) systems yielded fewer nucleated cells (0.35 × 105 cells/g and 0.05 × 105 cells/g, respectively). The Celution System also yielded significantly more endothelial cells, CD34/CD31 cells, and adiposederived stem cells (colony-forming unit-fibroblast)
REFERENCES 1. Aronowitz JA, Ellenhorn JD. Adipose stromal vascular fraction isolation: A head-to-head comparison of four commercial cell separation systems. Plast Reconstr Surg. 2013;132:932e–939e. 2. Pantilat S. Fast facts: Beneficence vs. nonmaleficence. Available at: http://missinglink.ucsf.edu/lm/ethics/content%20pages/ fast_fact_bene_nonmal.htm. Accessed December 4, 2013.
Reply: Adipose Stromal Vascular Fraction Isolation: A Head-to-Head Comparison of Four Commercial Cell Separation Systems Sir:
I appreciate the concerns expressed by Dr. Seong Kee Kim regarding the results of our recent study showing substantial differences in pluripotential cell yields and residual enzyme among between the four devices tested. A trained technician operated each device using the manufacturer-recommended protocol and the reported results have not been disputed. Dr. Kim is correct to raise the issue of residual enzyme levels in the separation product and it is certainly worthy of a brief discussion to clarify the issue. All efficient cell separation processes depend on some combination of Clostridia histolyticum–derived collagenases and a neutral protease to free progenitor cells from intercellular connecting proteins such
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