Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.

Summary: Abdominal wall tissue expansion is a unique technique that seeks to augment and expand both the fascial and subcutaneous tissues/skin layers to achieve durable closure of otherwise challenging ventral hernias. In addition to allowing primary fascial closure in a majority of cases, this technique enables reduced tension on the closure, potentially decreasing the recurrence rate. This article describes the senior author’s surgical technique for abdominal wall tissue expansion in massive complicated ventral hernias. The plastic surgeon is at a unique advantage to assist with the repair of massive complicated ventral hernias given their comfort with complex tissue handling and expandable devices. This specialized technique thus provides an opportunity for plastic surgeons to serve as expert co-surgeons with general surgery colleagues to help achieve superior outcomes in patients with these challenging hernias.

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