Plastic and Reconstructive Surgery • May 2015 related dissipation of her right arm swelling by means of several follow-up phone consultations. Approximately 18 months after transverse cervical artery vascularized lymph node transfer, the patient presented to a second surgeon requesting debulking liposuction of the left leg. Right arm swelling was noted on physical examination by the second surgeon. A third lymphoscintigram was obtained (not shown). No tracer uptake was demonstrated in either groin or in the right axilla (these results were reported in an abstract presentation by the second surgeon at the National Lymphedema Network Annual Meeting in Washington, D.C., in September of 2014). She reportedly underwent uneventful left lower extremity liposuction debulking performed by the second surgeon without any contact with the initial surgeon, thus leaving the initial surgeon unaware of the progression of the donor-site morbidity. This communication relates the first reported case of iatrogenic upper extremity lymphedema from a transverse cervical artery vascularized lymph node transfer. Teaching has focused on the potential risk of secondary lymphedema of the head and neck in the setting of a supraclavicular flap harvest. This case highlights the need for the use of ipsilateral upper extremity reverse lymphatic mapping when using a cervical approach.1,2 Furthermore, this case illustrates variability in the quality of lymphoscintigraphic imaging versus a putative dynamic presentation of primary lymphedema. Review of the three sequential lymphoscintigrams of the nonoperative right lower extremity revealed an illusive appearance of inguinal regional lymph nodes only on the second study. Such variability begs further investigation.3 This case demonstrates the importance of coordinated care and collection of outcomes data in the expanding field of lymphatic reconstruction. Because lymphedema patients are often moving from surgeon to surgeon hoping for a surgical cure for this chronic, debilitating disease, it is not uncommon for patients to be lost to in-person clinical follow-up. Therefore, it is imperative that we as surgeons develop a system within Health Insurance Portability and Accountability Act guidelines that allows tracking of patient-centered outcomes and morbidity. I would call on the American Society of Plastic Surgeons to initiate a patient registry for the surgical treatment of lymphedema to track patient outcomes and morbidity. Surgeon participation in a national registry would result in total transparency and an improvement in the quality of care for this high-risk patient population. DOI: 10.1097/PRS.0000000000001202

Marga F. Massey, M.D., C.L.T. The National Institute of Lymphology, Chicago

Dhanesh K. Gupta, M.D. Northwestern University Feinberg School of Medicine Chicago, Ill. Correspondence to Dr. Massey The National Institute of Lymphology


505 North Lake Shore Drive, Suite 214-B Chicago, Ill. 60611 [email protected]

DISCLOSURE Dr. Massey is on the Medical Advisory Board of the National Lymphedema Network. The authors have no commercial associations that pose a potential conflict of interest. REFERENCES 1. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: A new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135:277–285. 2. Klimberg VS. A new concept toward the prevention of lymphedema: Axillary reverse mapping. J Surg Oncol. 2008;97:563–564. 3. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315.

Trust Sir: t is impossible to ignore the election season, with the candidates’ advertisements a constant presence on my television screen. No matter the party, the message is always the same: you should trust me. Trust is important in the practice of medicine as well. Every day, we ask patients in our care for their trust. Yesterday, I went into the operating room to greet my patient who has severe rheumatoid hand and wrist deformities. I outlined to her, as I always do before surgery, the potential for complications and adverse events. My patient did not say anything as she listened intently to the descriptions of the surgical procedures I would perform. When I was done, she uttered a few compelling words, “Dr. Chung, I trust you; that’s why I came to you.” At that moment, I did not think much of what she said; I have heard it many times from the patients who seek me out to care for them. As a daily routine, I reflect on the events of the day so I can appreciate what I have done well and learn from what I can do better. What my patient uttered to me today, “I trust you,” resonated with me. When someone says they trust you, it has profound emotional meaning. People say trust takes years to build, seconds to break, and forever to repair. As physicians and surgeons, the trust that our patients put in us is an incredible, intense bond between two people who, let’s be honest, hardly know each other. I always feel an immense responsibility to my patients even for the simplest procedures such as carpal tunnel surgery or cyst removal because the patients have placed their trust in me to make their lives better. This trust is even greater when parents put the lives of their children, their most precious gifts, in my hands when I conduct surgery. On reflection, when that patient utters those words, “Dr. Chung, I trust you,” the gravity of those words underscore the special relationship between the physician and the patient. Changes in the health care environment have made most of our communications with patients electronic.


Volume 135, Number 5 • Viewpoints The physician-patient relationship has changed, and we as physicians and surgeons need to strive to connect and build trust with our patients. After all, it is these sacred human bonds that call on us every day to get up and make life better for someone in need. I recently came across an online story in which a father and young daughter are crossing a creaky bridge over a roaring river. The father, obviously quite nervous about crossing the river, said to his daughter, “You hold my hand and then we will walk across the bridge together.” The young girl countered, “No dad, I want you to hold my hand.” The dad looked at his daughter incredulously, “What is the difference whether I hold your hand or you hold my hand?” The girl looked up at her father and said, “If I hold your hand and we fell into the river, I may have to let go of you; but if you hold my hand, I am certain no matter what happens, you would never let me go.” As I walk into the operating room pondering the meaning of the word trust and as I hold my patient’s hand as we talk before surgery, I know I will have to put my best effort forward, for she has put the ultimate trust in me. And I will not let go of her hand. DOI: 10.1097/PRS.0000000000001201

Kevin C. Chung, M.D., M.S.

Section of Plastic Surgery University of Michigan Health System 1500 East Medical Center Drive 2130 Taubman Center, SPC 5340 Ann Arbor, Mich. 48109-5340 [email protected]

DISCLOSURE The author has no financial interest to declare in relation to the content of this communication.

Use of Smartphone Cameras for Simplified and Cost-Effective Video Recording of Microvascular Techniques Sir:


s surgical education evolves toward more outcomebased measures, methods for objective and accurate evaluation of residents will be increasingly necessary.1 In microsurgical education, there is currently no standardized method of training and evaluation; however, global rating scale assessment instruments have been validated.2 These require senior microsurgeons to grade live or video-recorded operations performed by residents in simulation laboratories. Recent Plastic and Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (

Reconstructive Surgery Viewpoints have discussed software tools that facilitate assessment by simultaneously displaying recorded video and the evaluation form to be completed.3 Smartphone coupling to microscopes or other optical instruments has been used in pathology, ophthalmology, dermatology, and hematology, and for global health and teleconsultation. Although photography is commonplace is plastic surgery, the literature includes few applications of smartphone cameras, such as an app for postoperative free flap perfusion monitoring.4 The senior author (M.A.) has previously experimented with consumer digital cameras in microstructural photography.5 We present a simplified and cost-effective method for video recording of microsurgical operations using a smartphone’s high definition camera coupled to an operating microscope. During the annual microsurgery training course at our institution, we experimented with coupling smartphones to an operating microscope with an additional monocular viewing eyepiece (Fig. 1). After developing prototype adapters, which were functional albeit cumbersome, we discovered the many commercially available adapters for this purpose. We selected the Snapzoom (HI Resolution Enterprises, Honolulu, Hawaii) adapter because it is low cost, universally adjusts to different phone models with or without a protective case, and is designed to attach to either binocular or monocular eyepieces in the widescreen mode. Once positioned properly, the smartphone camera recorded high-quality video while displaying video on the screen (Fig. 2). (See Video, Video Supplemental Digital Content 1, which demonstrates a rat femoral artery anastomosis recorded using a smartphone coupled to an operating microscope. The quality has been reduced to ease online access; however, the original quality is high-definition 1080p video, http:// It was possible to broadcast live video to a computer using video-sharing programs such as Skype (a division of Microsoft Corp., Redmond, Wash.). Typically, a black rim was visible, even when properly positioned, which could be easily removed by digital zoom on a camera app. As smartphones with high-definition cameras are ubiquitous among plastic surgery trainees and faculty, this method presents an affordable alternative to expensive clinical-grade video solutions for the recording of microsurgical simulations. Multiple adapters can be used for recording multiple residents simultaneously. Disadvantages of this method include limited storage space on many consumer smartphones and that, unless a third eyepiece is available (Fig. 1), the second microscope eyepiece must be used for the camera instead of by an assistant. Future developments should focus on directly recording video to a networked location where it can easily be stored, accessed, and evaluated by attending surgeons. In conclusion, a simple and affordable smartphone method for capturing high-definition video recordings of microsurgery training operations is presented.



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