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um.welcome to anyone else who's joined us.um just.now for jose's talk on super micro.surgery.more than just vessels so my my dear.friend jose.ramon rodriguez is from i had san diego.of meeting jose when we both did our.micro surgery fellowships at the chan.gun.memorial hospital in taiwan he was.already a consultant by then in chile.before he came on to the fellowship.and after that he took yet another.fellowship in japan this time.focusing more on super micro surgery so.he seems to love operating on things.that are smaller and smaller.as he gets bigger and bigger in the gym.so jose has always been an inspiration.to me because he's.so very passionate about his work and as.well as being a top bloke.so jose thank you so much for joining us.and we.very much look forward to your talk.dear james can you see the screen.perfect i can see and i can hear okay.thank you so much.let me check okay.so good morning everybody thanks uh for.having me this morning it's a real honor.for me to be here especially.considering that the whole webinar.series had been covered by.very big names in plastic surgery so i.have to thank.james for inviting me it's true that uh.i've always liked to handle flaps with.small vessels and try to also make it.thinner and smaller and probably that's.um.kind of a personal interest that's.called into the field of supermarket.surgery so what i try to do in this talk.is try to show you what has been my.approach to getting to this field.starting from simulated training to.pre-operative planning and then going.into practice.and how to make that effective enough.so even though i came back from japan.like around six months ago.i tried to collect my own clinical cases.but probably for.more complex reconstruction especially.considering this pandemic time.i also asked my mentors if i could show.you some.cases that may be interesting.so this talk will be divided first on.the.trying to elucidate if supermarket.surgery is just about smaller vessels.anastomosis.or it's about something else like a.whole complete new strategy.and then we will talk about training in.super micro specifically on.using non-living models some keys in.pre-operative planning and that will be.specifically focused on the use of.ultrasound performer mapping and then.talk about super microsurgery in lean.reconstruction.and a nice concept of what is lymphatic.flow restoration.after trauma so i had the chance to meet.the.james in 2016 when we were doing a.visiting scholarship.at chang memorial hospital at that time.we only met each other for like maybe.one or two weeks.so also we have uh probably you know.this guy anton.which was already a clinical fellow at.that time.and then we were lucky to spend one year.together as a microsurgical fellow.in changgang and probably the exchange.of experiences and the.friendship that you build with people.all around the world.may be actually the the most valuable.thing about this.year of training besides the massive.case load and all the.learnings that you can do also.technically.but then why some why i thought about.some additional training in super.microsurgery.and the thing is like when people start.handling.vessels i mean flaps with smaller.vessels and also doing lymphatic surgery.then it's some sort of distinction in.between these two fields.so typical microsurgery some people will.actually call it conventional.microsurgery.it's about vessels with one to three.millimeters but then what happens when.we.are working with vessels below 0.5.millimeters.and we will see along the presentation.that there are many details that.are relevant if you want to have success.and you have also.tried to put that into practice.regularly so.i tried to focus on the pre-operative.studies for flaps and lymphedema.on the execution of lbas on the whole.concept of the perforator.perforator approach on and also how to.perform and handle thin ultra thin.or the pure skin paraphraser free flaps.which are only composed by.skin so that's why i thought about uh.professor koshima we all know he's the.father of super microsurgery and.probably the pioneering modern lymphatic.surgery.and also one of his main contribution is.he left a very significant legacy of.students.particularly i i contacted dr yamamoto.which became my mentor in.training and also some other very well.known doctors i had the chance to visit.during my stay in japan.i got torseki in lymphedema akitatsu.which is very well known for.ultrasound technologies and lymphedema.and flap planning hidehiko.well known also for skip and lymphedema.and dr mihara which is an expert in.lymphedema surgery.so dr yamamoto even though he may look.younger than most of his fellows.he has more than 100 articles as first.author.and he has been also well recognized for.validating the use of icg lymphography.and multiple super micro surgical.techniques.in different fields so let's get into.the.topic of super microsurgery if it's only.about just smaller vessels.and we come back again to the figure of.dr koshima.which introduced the concept of.supramicrosurgery in 1998.when he published this article about the.umbilical.perforator flap so obviously this flap.consisted uh on a flap with smaller.vessels since it's.it was like a deep inferior gastric.artery flap.but the perforator was transected at the.point where.it pierced the muscle so the muscle was.preserved and the whole actual vessels.were preserved too.but if we take into consideration what.happens when you do this.it's like you don't only have a flat.with smaller vessels.but also you have a reduced time for.dissection.you have less donor side morbidity and.it also gives you more freedom.in terms to customize the flap thickness.so it's a whole new strategy.that you put into practice trying to.optimize.both on the several steps that take into.place during microsurgery.and only in 2010 they finally defined.what the super microsurgery concept.was in a clinics of plastic surgery that.was written by the japanese.group so it consists in the techniques.of.micro neurovascular anastomosis for.small vessels and nerve fascicles.that are around 0.3 to 0.9 millimeter.obviously when you handle tissues of.this.external caliber you need to have.delicate micro surgical instruments.and also find sutures materials with.needles that are around 30 to 80 microns.so if we can have like a very gross.comparison of different fields in.vascular surgery.it's obvious that as you go smaller and.smaller.even microsurgery can seem to be a large.vessel.when you are handling vessels or of.around 0.3 millimeters.so there must be something special about.how to do.and how to perform anastomosis on these.kind of vessels.and then the the field as the field.expanded probably the the most.well-known area for training on smaller.vessels are.distal digit replantations so when we.have replications in tamai.zone one or even some two especially for.the.veins sometimes it can be very very.troublesome to.identify and this was probably the.largest.area where microsurgeons could train in.super microsurgery.but then pushing the boundary a little.bit further even for.digital digital reconstruction we we.know that.we can perform toe transfers but.what about doing partial toe transfers.and just trying to reconstruct the.distal phalanx.in order to maximize the aesthetic.outcome.and at the same time to preserve the.donor site.so that was uh as confidence was being.earned.they pushed the boundary a little bit.forward into more complex reconstruction.and the same for head and neck.reconstruction for example using the.commissure of the first web space of the.toe.and doing also like small anastomosis.in the head and neck which usually is an.area where.you want to have big vessels and be.confident about.and obviously the whole spectrum of.lymphatic surgery which is the.the most well-known field for japanese.microsurgeons.so this whole spectrum of areas and.procedures.was like the incorporation of the whole.super micro surgical approach.into reconstruction of different areas.but also we must recognize that during.the last.probably one and a half decade the group.of professor jp hong and the.whole korean group that have been.focusing mostly.on limb reconstruction have helped to.popularize the concept of.using super microsurgery and this was.nominated as the next step in evolution.because it definitely offers several.advantages in terms of dorsal morbidity.and operative time.so basically the advantages of super.microsurgery were stated during the.first article of professor koshima and.remain.more or less the same we have a reduced.operating time for flap elevation as we.use.short verticals there is minimal.duraside mobility.because we are able to minimize.dissection and also preserve muscles.we are able to tailor flood thickness.according to the defect requirements.and as we use perfectors as recipient.vessels in some cases.this gives a whole new spectrum.of recipient sites with increased.versatility.and obviously the whole area of.lymphedema surgery including lba.the concept of lymphatic vessel transfer.and the treatment of lymphocytes.about the equipment i would say that.although.it's definitely useful to have fine tip.instruments we don't really need to have.such a wide array of instruments.actually the key points.are first the forceps ideally having.0.05 and 0.1 millimeter.tips and also good needle holders of 0.1.and 0.2 millimeter tips.and about the sutures even though.nowadays people are.also trying to introduce 30 or 20.micrometer needles.actually if we have 12 volt and 11 0.with.5 50 micrometer and 65 micrometer nils.that's is usually enough so these are.the.available sutures they're usually in.japan for example they're handmade so.they're very lucky they have them.available.but in most of the places we are able to.find 50 micrometer or 65 micrometer.needles.which should do the work pretty well.what about training in super micro so.the first question is is super.microsurgery for everyone.and i think that the answer is probably.yes i don't believe that.most of these techniques are only for.very capable.people or super talented surgeons.probably.yeah it requires people who is dedicated.but then the next the next question is.does it require additional training.and i believe that the answer to this.question is absolutely.so in 2016 i remember we published this.uh.idea of uh validating a training.curriculum based on non-living models.because i've always been a big fan of.using.non-living models for training i did not.believe that.using animals was justified in order to.acquire skills.and at that time we used the chicken.wing and the chicken thigh the chicken.wing was.for smaller vessels and this was the.ulnar.so i remember that at that time when we.saw the concomitant veins of the owner.archery that were very very tiny.we thought probably we are not able to.connect those vessels.and we did not use them at all so our.same group later.published a modification of the.chicken leg model in order to train.super microsurgery.but it involved quite an extensive.intramuscular dissection.in order to reach primary or secondary.branches that were below.0.5 millimeters and the group of.professor.wei chen also did something very similar.and they were able to classify.primary secondary terminal branches and.at that point.they could reach vessels that were below.0.3 millimeters.and did a very nice classification of.the whole spectrum of vessels that you.could.use uh sorry identify when we're using.the chicken thigh.but actually uh i i'm a big fan of the.chicken wing for super micro training.so uh we i came back to dissecting the.ulnar artery concomitant veins while i.was in japan.and tried to standardize uh what was the.the vessel diameter when we did this.and as you may see there is no.intramuscular dissection at all we just.took the ulnar artery.and actually the external diameter of.the concomitant veins.is around 0.35 millimeters and the.communicating branches that.usually you may find around three to.four.in each set of vessels are around 0.2.millimeters.so these are a whole array of vessels.that usually are below 0.45.and may actually reach 0.2 or 0.15.so when you approach the middle wing and.specifically the ulnar artery on comet.and veins.you are able to find a whole set of.vessels for training.when you use veins i think they better.resemble lymphatics.as the it's more difficult to identify.the lumen.and also you can have enough vessel.length which is very useful.when using non-living models because.vessels usually retract.quite easily and as you may know lva.is performed under no tension at all and.having multiple vessels close to each.other.allows you to have different anastomosis.configurations like.we are seeing here so you can do a side.to end side to side end to end in.different orientations.and it's a quite good model for training.and on the other side if you want to try.anastomosing artery to a vein so you can.feel different textures which also may.happen in the.real life scenario the distal wing also.has a very convenient anatomy.you may find the medial subcutaneous.vein which is the one that we see in red.here.and just underneath the muscle you can.find the ventral metacarpal artery.and when you cut them actually you get.vessels which can be orientated in a.very similar way.to an lba setting so i think that the.chicken wing is a very good model for.training.what do we need actually for training we.don't need too much things.too many things sorry and it's not.really that expensive.fine tip instruments which can be.obtained.through commercial sites a stainless.steel gotch so we can.make sure which diameter are we working.on and probably the more complicated.thing to obtain is the small sutures.so ideally finding a non-sterile suture.will help to save.quite a lot of money and about the.microscopes.actually we are have been told that we.need very fancy microscopes for training.but.the truth is that we can get enough.magnification if we reach 20 to 30 times.so we have cheap cheaper options or a.little bit higher quality.which can be both on affordable price.for any kind of institution.but a key point during training and also.during practice of super microsurgery.is the idea of changing the microsurgery.mindset.we have always been told that we require.vessel cannulation before suturing i.mean.introducing the forceps to make sure.that we can see the lumen.but in super micro that's very uncommon.especially when we are working on.vessels below 0.5 millimeters.so then the needle feeling becomes very.important.the needle helps to dilate the vessel.and also to confirm that we are inside.the lumen.it's also important to have small bites.as we need to avoid.inversion of the anastomotic site.and the tripod pinch here becomes.crucial.since during microsurgery we can just.put pressure on our wrists.during super microsurgery our wrist.is it's at the level of the mp joint.so you can see here that the forcep is.actually at the base of the index finger.and the tripod is done just because of.using the.thumb and the third and fourth finger i.think that's the best tripod for super.micro.and also as we are working in high.magnification.every movement of the hand may signify.a change in the focus so we need to.heavily rely on the use of the foot.pedal.so in summary for training i think.chicken wing and.it's the non-leading model of choice i.really recommend using veins as their.more challenging.challenging story there is very little.intramuscular dissection required.and it's important to change the.microsurgery mindset.so the main and key point is to train.train and train more.and actually when we don't have a lot of.cases recently we are always available.to train a little bit on the chicken.wing.whenever we want to and we want to feel.a little bit more comfortable.what about the keys for pre-operative.planning.so probably these are the three main.instruments we use.for perforator mapping the handheld.doppler which is.always being used day-to-day city and.geography.and i will really go like to go into.more detail.about the ultrasound color-coded duplex.sonography.so city and geography has several.advantages as it is non-operator.dependent.it is fast and easy to read and it also.allows 3d reconstruction.including also augmented reality which.has been published by.some friends here in chile also but it.does have some disadvantages.like for example the presence of.radiation and.the main point i think is that it's less.accurate for vessels that are below 0.5.millimeter.we have no chance to assess the.intradermal perforator course.and also we don't have the chance to.measure the real-time blood flow.of these vessels even though we may.select the flap thickness according to.the analysis of the images.i do believe it's less accurate than.using ultrasound.color-coded duplex sonography which is.combining the different modalities of.the doppler.effect during ultrasound has the highest.sensitivity and positive predictive.value for peripheral.identification it allows us to detect.vessels.right above 0.2 millimeter and it also.helps us to measure and evaluate the.blood flow which can be done.in the side bed by their own.microsurgeon.the main disadvantage obviously it's.operator dependent and it has a learning.curve.but i do believe that as we are.microsurgeons we.have a very detailed knowledge of the.anatomy so.it's really easier to interpret what we.can see.on the findings of the ultrasound and it.can be time consuming usually.we could spend around 30 to 40 minutes.for a.very detailed mapping of a specific flat.so it's also very true that when we see.an ultrasound it's a matter of.frequencies.so in the conventional.ultrasound we will use high frequency.ultrasound which is.right above 10 megahertz ideally it.should be 12 megahertz but these are.multi-linear transducers so they have.different frequencies.resolutions for this type of ultrasound.machines.can reach around 0.2 millimeter and we.usually explore in between one to five.centimeters of depth.but then ultra high frequency ultrasound.which is.above 30 megahertz has revolutionized.the whole.imaging concept these uh have usually.two pros of 48 and 70 megahertz.and resolution can be 10 times higher.reaching even 30 microns.the depth for the 48 megahertz.transducer is around 25 millimeters.and for the 70 megahertz it can reach.only around 10 millimeters.and the most well known equipment is the.vivo md.that was developed by fuji so when we.work with the ultra high frequency.ultrasound.we are just focusing on the sub.centimeter range.and this is a case example with high.frequency we can have.nice resolution we can identify every.structure.but then if we go to to the ultra high.frequency sorry.then we just get a much higher level of.detail.and we are focusing just specifically on.a more superficial range of the image.and i would really recommend for those.of you that are interested on the.concept of mapping your own flaps and.trying to identify.different layers and so on to read these.two articles that were developed by dr.kerr from germany and i think that they.set up a.very very well structured step-by-step.guide.for ultrasound based mapping so the.steps.of ultrasound guided performer mapping.are first to identify tissue layers.so in order to assess the flap thickness.the deep and the superficial fascia.then we locate the peripheral at the.deep fascia level.and then we are not analyze where the.perforator is going into the subdermal.level.it's important to analyze the infra and.the superfacial.cores and we can also measure blood flow.these are the ultrasound modes i'll try.to make it kind of.simple and so we can you can feel that.it's actually doable by any kind of.surgeon.we have a b mode which is like a two.dimensional mode which.shows a grayscale map and it's important.to assess the tissue layers so it will.show you the macro anatomy.we will see later on that this is the.main kind of.actual cat for the skip flap planning.and then we change to the colorful mode.which is the standard color coding mode.we have a color box with a doppler.effect.and in during darker color doppler mode.sorry.blue means that it's going away from the.transducer and red.towards the transducer the power doppler.mode it's like a variation of the.colorful mode.which enhances sensitivity by a factor.of three to five.here we can see usually smaller vessels.or.vessels that are in a more superficial.level and.it's independent of the flow direction.so always will be shown as a red image.and e flow is sometimes used it's like a.digital subtraction technique.not doppler and it can show you the.microvascular network at the superfacial.level very clearly.and finally the pulsed wave mode is the.final step during.peripheral mapping and we use it for uh.assessing the perforator flow.we know that for perforator flaps the.flow usually.ranges between 5 to 30 30 centimeters.per second so this is the standard.knobology for.most of the equipments we have a b mode.e flow color flow.and pulse wave and here we have a touch.screen which will show the power doppler.that cannot be seen.in this screen so there are several.settings.i know these numbers may be confusing.but i just lift here.in case you want to start trying with.the ultrasound and these settings are.very important as they increase.sensitivity to identify small portfolios.so.it's like a 10-step commandment that has.been already described.so you can try and you will see how.ultrasound become.much more easy so we start with bebo.and we assess tissue layers then we.change to colorful mode and we identify.the perforator at the deep fascia.then we go for power doppler and we.identify the perforator course on the.superfacial level.eflo is sometimes used to visualize the.vessels with different flow velocities.and it gives you like an angiography.like image and then pulse wave mode.helps us to know the blood flow velocity.of the peripheral we are using.in this case i would like to show you.what we want to see for the skip flap as.is.like the workhorse flap for super micro.surgery.and as you may know the skip flap has a.superficial branch.and a deep branch the deep branch.usually goes right next to.the serratorius muscle fascia and then.pierces the fascia giving.different branches either to the skin.bone.nerve or even the muscle so.as the skip flap is usually based on the.superficial branch because it's easier.to dissect and it's much more.straightforward.so in this case we want to know where.the superficial branch is piercing the.deep fascia.and then also where this branch is going.into the skin.and if it's ideally an actual vessel.what would be the course of that vessel.into the skin.but about the deep branch we also want.to know where it reaches the deep fascia.and what will be the course of the deep.branch in case we want to use it.which is especially useful for chimeric.flaps so.here's a case example of like a mapping.a skip flap.we first start with the region where we.kind of anticipate where the superficial.branch pierces the deep fascia.and here you can see the superficial.fascia femoral artery.the femoral vein sartorius muscle deep.fascia and the dermis.and this is usually the area where the.superficial branch.will pierce the deep fascia and go more.superficial.so b mode only helps us to have like a.sort of.macro idea of the anatomy.and then we change to colorful mode.i don't know if the videos are are being.watched now.i just included some pictures in case.they they are not able to see.very clearly but here we have the.femoral artery.and where we are looking is to try to.identify the vessel coming from it.and piercing the deep fascia here so i.hope i wish that you can see this.like the emergence point of the.superficial branch.going right through the deep fashion.it's very difficult to see the whole.vessel going in that.in that specific point but as you move.the probe you are able to kind of.anticipate what is the course of the.vessel.so these are the images that we were.just seeing in case the videos did not.work so this is the femoral.artery this is the point where the.superficial branch is piercing the.fascia.and here you can see the diagram and.then.we can also see what is the deep branch.takeoff and what what is the course in.relation to the sartorius muscle.so the difference will be located a.little bit more distally compared to the.superficial branch.this is the takeoff point this is.sartorius muscle.and then we see how the artery and the.two veins.go right next to the fascia of the.sartorius muscle.so once again here to show you how what.is the takeoff point and.how it it is located much deeper than.the superficial branch.and then we change to the power doppler.mode and the main objective.here is to try to trace in the skin.what would be the actual pathway of the.vessel.so we can locate our flap right over the.vessel and we can be.really accurate with this fact we are.not guessing.that probably the vessel will be located.there we want to be completely certain.that our flap is centered in the actual.and the axiality of the vessel so power.doppler.gives us the chance to check both.simultaneously the superficial branch.which is over the superficial fascia.and the deep branch which in this case.is below the deep fashion.so if we want to take a thin flap.obviously.we can base our flap on the superficial.branch.and here if you go a little bit more.into the iliac spine.usually the superficial branch will give.several branches into the dermis and you.may see with how.impressive is that you can actually see.even though this is no not ultra high.frequency ultrasound.how the perforator is distributing into.the skin.that's very important for planning ultra.thin flaps.this is the summary of the images we saw.before so we have superficial branch in.the upper part of the screen and then.deep branch below the deep fascia.and this will be the area where the.superficial branch perforator.is distributing into the dermis and.finally.we have a e flow which gives you like.this kind of.arteriogram kind of image especially for.vessels underneath the fascia.and we can also measure the systolic.velocity and end diastolic velocity.this was a good perforator with a fixed.systolic velocity of over 30 centimeters.per second.which is considered as good but ultra.high frequency ultrasound.obviously gives you a different.perspective of of.images you can really see the.intradermal course of the perforator.and then map your flap accordingly so.you can have.a very very thin flaps like the one we.are seeing here.just composed of uh skin basically.and that gives you the chance to.resurface different defects.with a very nice contour this is another.publication showing the same idea.so you can see the scale of the ultra.high frequency ultrasound is much.lower and here we are working around 3.5.millimeter.depth over the superficial fascia and.still you can see the perforator.distributing into the dermis.so let's get a little bit more into.clinical examples.of supermarket surgery in limb.reconstruction.summary of key principles that i usually.use nowadays would be to try to use.recipient vessels that are in proximity.to the defect or even within the defect.the flap design and the thickness is.always customized to the difficult.characteristics.and for small to medium size defects we.usually use.skip fab for large size defects will.change into the alt flap elevation for.the skip.in particular is performed from proximal.to distal.above the superficial fascia and using.electroculturing.and we usually use also the handheld.doppler.uh in the opera operating table so we.can.easily uh use it when we are not able to.find a perforator or when we.we want to confirm our markings so i.think it's very very helpful to have it.over the table for arterial anastomosis.we will do.into site for the main vessels and end.to end when we use perfect.perforator and for venus anastomosis.basically would depend.according to the size discrepancy we.always consider the fact that.the patient may benefit from immediate.lymphatic flow restoration.and i will go to this concept a little.bit.forward during this talk and we use.interpretive and possibility.prostaglandin e1.and we start with possibility flap.compression.on post-operative day 5-7 as the group.from korea.already has suggested in a previous.publication.this is a very nice idea that takumi.always emphasized.and i think that for super microsurgical.dissection.we need to highlight the importance of.the interlobular dissection plane most.of the extractors on the.super microsurgical level i mean over.the superficial fascia.or right below it will lie in between.the fat lobules so we never try to tear.or.cut the lobules in the middle we just go.in between the septa.using electrocautery so we keep a.bloodless field.and we also preserve structures this is.particularly relevant for.uh ultra thin flaps and also for lda.as we want to identify venules in the.superficial layer.and then reach the superficial fascia.expose it very clearly.and approach the collector lymphatic.vessels that will always lie.underneath the superficial fascia.and then there are different methods for.harvesting the skip flap this is the.more popular one i believe that was.introduced by professor hong.and in this case they designed the flap.following um a sort of um axis that goes.from the groin crease.to the superior elec spine and then they.perform a lateral incision and explore.the flap.it probably is very fast for experienced.hands but.in my opinion it has the drawback of.giving you a little bit.of guesswork in order to find the deep.branch of the scia first on the more.lateral part.and then the superficial branch once you.reach more medial.so then the japanese group has.popularized.a different method that was also.introduced by hidehiko.and i think it's quite useful since it.helps you to reduce the guesswork.it also allows you to have a longer.pedicle and assess the superficial.branch.versus the deep branch versus the seia.so you can choose the vessel that has.the largest caliber.and it's also very very useful when you.want to include chimeric skip flaps.so what you do in this case is you.perform like a sort of transverse.incision.right at the base of the origin of the.scia.and then you can find the scib and scia.very easily.i'll show you some cases using this.approach.so the superficial circumflex in the.artery system.may is composed as you know a.superficial branch when we based our.flaps.on this branch we can have the skin fat.and lymph nodes.and when we use the deep branch we can.do a very versatile flap.which not only will include skin fat and.or fascia.but also we can have nerves like the.lateral thermal cutaneous nerve.we have muscle branches so we can take.some a piece of the sartorius muscle.or even include the iliac bone if we.take some branches that come from the.deep branch.right next to the iliac spine these are.um.some illustrative cases this is a 30.year old 13 year old male story.he had a complication after orthopedic.surgery.so what i did here is plan a skip fab.based on the superficial branch i trace.the axis of the.of the artery and then plan to do a.proximal to digital approach.incising the base of the flap first and.as you may see.after a very straightforward exploration.you can actually see the.artery and the vein you expose the.pedicle and you immediately feel conf.confident that you can see the vessels.and then you.also that the axis of the flap has been.well designed.so here we have completed dissection.this patient was a little bit overweight.but.we did dissection over this the scarpa.fascia.you may you may see the sciv and the.scis.this is the flap after transection and.uh.this is the immediate postoperative.result usually end to site anastomosis.even the vessels can be small.helps you to achieve a good size match.and makes it much more easy even for.veins.and this is the uh i think two weeks.follow-up.we usually use uh negative pressure for.the donor side.when we have high risk incisions since.it's available in our institution.this is another case it's not a free.flap but i wanted to highlight the.importance of ultrasound mapping.so this is a patient with a complication.from vascular surgery then she.experienced necrosis of the.immuno region and we were not sure if.the superficial branch of the skip flap.was uh still patent so we did.ultrasound mapping and we just explored.this area.so actually we could find the scis was.still paid in and.was in good condition and we harvest the.flap then based on the superficial.branch.and as you may see the axis of the flap.here that.the of the vessel sorry they match very.very well.with the distal end of the superficial.branch so ultrasound.is really really useful in this aspect.then here we have the flap and we use it.as a propeller.so we could cover the defect you know in.a very.nice way this is a different uh.a different case um i did it actually.before leaving for the fellowship so.um it's a 75 year old male he had double.total knee replacement and we did this.with my mentor here in chile.he had occlusion of the superficial.femoral artery and he was just getting.perfusion by collaterals.and this you may see it's a completely.different design of the flap.similar to the one that i show at the.beginning with the lateral approach.so we just try to find at that moment.the point of.performing the deep fascia and then we.just follow this axis.into the groin crease toward the.anterior relax spine.so when we explored the knee actually.what we only found was a.very fibrotic tissue everything was.covered by this thick capsule.and uh through intraoperative handheld.doppler.mapping we we heard like a uh arterial.signal here.and we did a very careful exploration.actually we found.this innominate perforator that was very.very tiny but.surprisingly had very good flow so we.harvested the skip flap we had a.superficial.subcutaneous vein here that is being.held with a clamp.and then we had artery angle comet and.veins so we hook up the.scis and the concomitant vein they were.below one millimeter i think.and also the subcutaneous vein and we.were able to.uh sort out this the situation actually.this is the follow-up after six months.uh it has a good contour and this small.tiny perforator.could give us a good flow and this is a.different case.probably it's not super micro but i.wanted to show how you can tailor the.flap thickness.it's a patient with a motorbike accident.soft tissue loss.we map the perforator so with the just.mark our hot zone and then the rest of.the flap is harvested.really in a straightforward way and we.have a very thin flap we identified.both uh perforators just matching what.we saw on the.ultrasound and we went into decided also.for the veins here.and we had good contour with no need of.additional debulking.and these are a little bit more complex.cases a patient with a necrotizing.facilities of the right hand.we had to decide whether to do a.one-stage reconstruction with multiple.flaps or maybe bury the hand.on the groin we chose to use one skip.fab and alt.in combined surgery so what we did is we.hooked up the alt it was a little bit.thick because the patient had the thick.i think um pie even though we harvest.over the.scarpa fascia and then we took the.escape flap.and connected to the distal run off of.the alt.so we can see the vessels were quite.tiny but nice much.for the skip flap and this was the.immediate possibility of result a little.bit bulky and.here after we separated the fingers but.still need the bulking.although we could achieve a one-stage.reconstruction.and this case is from takumi i really.admire this case this was a patient with.a.scar contractor due to burn he.previously did.a pure skin perforator flap for the.dorsum of the hand so we can see the.donor side here.on the right groin and then he decided.to.resurface the four fingers with four.pure skin perforator flaps.from the same donor sites so we did.ultrasound to make sure that we could.find pristine performers.and then this was the defect exposing.the paratenon of the four fingers.and we can see the four tiny flaps very.thick it's just.more like a full thickness skin graft.and this is the result after transfer so.you can see that it gives you a very.nice contour and he.was able to have a good functional.outcome too.and the last case for limb.reconstruction this is a partial great.toe transfer.but this is a patient we had a traumatic.amputation of the distal phalanx of the.thumb.so we did as i said the partial greater.transfer but probably the most.tricky part of this surgery is also to.do a chimeric skip flap.including two pure skin perforator skin.pedals.and bone based on the superficial branch.and the dip branch.in order to resurface the donor side.so this is the flap after harvest very.nice.and good much with thumb and here you.can see the result two weeks after.surgery.and this is the result also of the donor.sites you may see that.the patient can keep the bone length and.also the skin will allow us to resurface.the finger.which will minimize the donor side.morbidity.and finally briefly i would like to show.you the concept of lymphatic flow.restoration after trauma.so there are a whole spectrum of.different procedures.in the field of lymphatic surgery the.ones that.involve super micro will be lva either.prophylactic or therapeutic.and the concept of vascularity vessel.transfer.the vascular lymph node transfer is more.like microsurgery and then excisional.procedures are macro.at all so lymphatic flow restoration.was introduced in 2018.and it consists in transferring a flap.with a high density of lymphatic vessels.either the skip flap deep or alt.then it's believed that may induce.lymphangiogenesis.in the recipient side once two.conditions.may need to be accomplished the first.one is that the.the flap needs to breach the soft tissue.gap so there are no.defects in between the uh the soft.tissue loss and the recipient side.and the second one is that we need to.confirm the lymph axiality of the flap.using icg so in this situation for.example.we may need to we need to make sure that.the flap.has the same direction of lymphatics.than.the recipient side and in this area we.should not.leave a raw surface of more than two.centimeters.so this is a picture from the.publication.a case of sarcoma excision they did a df.flap so they map the lymphatics here.which are.shown in red and then they did the.transfer.obviously they need to make sure that.lean faciality will match.the recipient side and it's very.impressive how after.uh follow-up around one year which is.the time that you need to.give the flap to show new lymphatics you.can see that the icg.which was injected distally would go.through the flap and actually will.restore the lymphatic flow.even though the defect was quite large.so these are another cases that.we were able to take part during the.fellowship this is a 45 year old.year old female story with a soft tissue.defect because of cellulitis.this is the icg lymphography before.surgery you can see.there is a stop of the contrast here.in the area of the defect which also.it's uh related to the fact that the.medial pathway of lymphatics was.interrupted.so we marked a skip flap here are the.icg.injection sites and you may see how the.lymphatics are going.towards the groin so we make sure that.the flap will contain lymphatics.this is the flap harvest again from.proximal to distal we recruit additional.fat.on the sides of the flap and then we.make sure that the.orientation of the flap will be.the same that we need in the recipient.side so.a will go distally i mean the distal end.of the flap will go distally.and the proximal will go proximal then.please apologize me for not having.delayed pictures of this case because we.could not do the.icg mag and last i would like to show.you this.crazy reconstruction it's a patient with.a whole.forearm deglobing after necrotizing.fasciitis.so we plan to do a lymphatic flow.restoration with multiple free flaps.and for that purpose we mark both alts.and two skips.and here you can see that the alt can.also be used.as a lymph axiality-based flap if you.are able to.[Music].try to identify the lymphatics using icg.lynphography.so for this purpose uh we did five claps.we did one lt which was split the left.side.right alt also one skip fab and then.when we tried to use the other skip flap.there was too much.tension on the closure of the donor side.so we changed to a medial serrature for.your flap.and this is the final result after three.weeks so.there was complete survival of the flaps.minor raw surfaces.in between the junction of them but.again i don't have the delayed icg.lymphography but it would be expected.that the.lymph flow may have been restored.so as a summary i think that uh even.though super microsurgery may.seem to be very complicated and kind of.pushing the boundary of.conventional surgery i believe that.adequate simulated training is crucial.for having an.acquiring proficiency and feeling.technically confident.a detailed pre-operative planning.especially when it's performed by the.own surgeon.gives you safety on pushing the limit.and.as we use short pedicles with minimal.dissection in small vessels.then that turns out to be a faster.surgery.but most of all i think key point is to.also.always enjoy super microsurgery.so thank you for having me here uh i was.really privileged to.uh take part in this webinar series and.i hope that.when this whole kobe thing is over you.may have a visit to.chile we have a very beautiful country.and we can enjoy red wine here.with beautiful landscapes thank you.great absolutely stunning talk i say.congratulations on.incredible cases thank you so much for.sharing that with us.i'm also a big fan of chicken wings as.you know deep fried.um and it's amazing how much chicken.anatomy you need to know to be a super.micro surgeon.so um should we go straight to the q a.section um just to i wanted to.um ask a question about um.choosing your recipient perforators do.you have a reliable way of.knowing um whether it's sufficient to.power your flap.yes so i think uh ultrasound perforator.mapping is crucial for.for that purpose what we do is we will.go.either if we can find vessels within the.defect as we did for example in the.little kid case um so actually in this.one i did not.uh really are you watching the.presentation still.yes yeah you can see that so i found.perfectors here in the digital part and.the proximal part but i thought that.maybe i could actually go.straight to the anterior tibial vessels.here so that's what i did and we.it was quite easy but if we don't we can.just go.um like in proximity to the defect do.ultrasound mapping there.and try to trace the perforator so you.can.first analyze it as we mentioned before.with color-coded power.powered author and then we will do pulse.wave topper.so we can have an idea of the flow at.the superfacial level.usually we standardize measurement of.the flow at the.right beneath the fascia so there you.can have like a nice caliber.and what professor hong has already uh.validated i think that when a perfecter.has over 15 centimeters by second.is usually a good perforator so when you.have that kind of flow range in between.50 to 20.centimeters per second but obviously.a key point also then is the.intraoperative exploration.so we really feel confident when the.when the artery is like a.having a very volatile flow then you.just double check.what you saw with ultrasound but that's.more or less the strategy.you very much i've got a question from.anton fries.who his picture you showed earlier so um.he says hi jose great to see you and.thanks for your wonderful talk.uh can you give us tips for recipient.vessel selection when using vessels in.or very close to wounds being.reconstructed i guess that touches on.what we talked about just now how do you.approach the zone of.trauma so for myself i'll be quite.hesitant i'm going to be too chicken to.go right into the zone of trauma.particularly if it's a high energy.threat um.injury or um or if there's a component.of the gloving that would make me worry.but.do you have a different approach yeah.i think nowadays we we're kind of.obsessed with.no even trying not to put much more.incision.beside the defect so um if it's a fresh.wound.usually sometimes you can actually see a.pulsatile vessel.right in the defect and if you do so.i'll just go.straight there and try to use it if i.don't.uh i will definitely extend the incision.a little bit.however um that may be a little bit.tricky especially for the skip flap.when you don't have enough pedicle so.the skip flap can be used with a distant.vessel.when you do the proximal to digital.approach so you just.explore the pedicle in the proximal part.and then design your flap a little bit.more distant.that gives you a lot more freedom to.move.uh distantly from the defect but the.original.way we did it in which we just center.the flap on the axis between the groin.and the.spine once you harvest the flap the.pedicle is actually.nearly non-visible it will it's just.attached to the flap so.it's kind of tricky but you know in.summary.i would always try to i know the sonar.trauma concept.can be a little bit scary but i think.that sometimes you can.clearly identify where the vessels are.good and.if you have a good flow interoperatively.there.then should be no problem at all okay.question from your friend juan berna.thank you jose for a great talk.the last slide made me homesick do you.routinely measure outcomes from your.lymphedema.patients objective assessments problems.what do you do.yeah definitely so um well these.patients are.non-lymphedema cases are they are.actually trauma cases that have a high.risk of developing.uh trauma related lymphedema.but on lymphedema patients we do.have a very wide assessment we have.objective measurements.which can be done like with.circumferential measurements or.better technologies like the parameter.and.we also include the subjective symptoms.like uh.occurrence of cellulitis tension pain.and the use of compression garments.and obviously patient reporting outcomes.are a major issue nowadays so we are.also including them.routinely during the evaluation of prio.and post-operative.outcomes and what i do.also which i like i took that from.takumi.we also follow our patients with icg.lithography.since the findings from isogel and.photography are the most sensitive.indicators of lymphedema when you follow.patients with icg.and there's no no progression on the icg.findings.or even sometimes you can see a minor.regression in some patient.patients sorry especially in the early.stages you can feel really confident.that the.things are working for the.volumetry that's a different.topic i mean same topic for objective.measurements there are different ways to.do it.most people would use the truncated cone.formula in which you just.use the circumferential measurements and.try to.estimate what would be the volume of the.whole limb but obviously there are.more accurate ways of doing that the.parameter probably gives you.a better assessment of volume and.there are other index which japanese.people use a lot.which correlate the circumferential.measurements with the bmi.we also use it as a reference great.um i was interested in your your last.incredible case with.five flaps first of all how long did.that take and.secondly um how do you monitor these.flaps post-operatively do you guys use.any kind of venous dopplers.cuffs things or or is it just pricking.the skin.just uh mostly pricking mostly pricking.uh that case we finished around 2 a.m.i think we had some we took a little bit.more time.with the when we changed to the middle.summer archery perfect flat.but um i i was quite impressed i.i the first time i see five free flaps.and as you may see in the post-op.probably no flap loss at all i mean or.very very minor you know.i think one key point because many of.these flaps i don't have here.like the whole circuit of connections.but many of them.are flow through you know so probably.there are only two of them that are.connected to a source vessel.they use prostaglandin um regularly in.japan for this kind of flaps.and they do it in a high dose so that's.very interesting so.in korea they have shown that the low.dose of pg.e1 works which will be around 20.microgram.a day in that continuous infusion but.the first day in japan they live.around 10 times more so i don't know if.it's.obviously technique and everything is a.key point but i also think that.sometimes using a good medication can.also help.and for monitoring they are not really.very very picky about it.just leave it like that.great and the final question from.shenzhen jing is high bmi.a contraindication for super micro.surgery.no no no at all i think that high bma is.a very good indication for super micro.because for example in western countries.just like the uk.or ours very few people would be have a.normal bmi.so when you do a limb reconstruction.specifically right when the.contour is very important and you want.to have like a very good result in one.stage.then sometimes that can be tricky right.you just want to make the flop survive.but it's very bulky.so then super micro can help you if you.want to tailor the flap to the adequate.thickness.and then you go to dissect the.perforator in a more superficial layer.and that requires just getting used to.the.dissecting in between fat lobules i.think that's the key point.dissection with uh electrocautery in.between fat lobules.and that's perfect that's much more.challenging with if you.hypertrophy fat love use and trying to.weight yeah.a little bit right but i think when you.don't tear the fat.uh before going to japan i i usually.would be like a.more blunt dissection tear than the fat.you know but.using the bowie but the flat bowie right.not the.needle kneel tip needle tip only for lva.flat bobby for uh perfect dissection.and then it's much easier much.straightforward.you just do traction and you cut on.where you're.doing traction and you can all even do.intramuscular dissection only with bobby.mostly no clips.yeah very nice okay great um we've come.to the end of the session thank you once.again so much for joining us.all the way from chile.and i'm sure we've all learned a lot i.have.you.

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