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Background Lymph node flap transfer has gradually gained popularity for the treatment of upper and lower limb lymphedema. The aim of this study is to present the outcomes of an integrated treatment protocol based on double gastroepiploic lymph node flap (DG‐VLN) and active physiotherapy in patients affected by Stage II and III lower extremity lymphedema. Methods All Stage II and III lower limb lymphedema patients operated between September 2015 and December 2017 were retrospectively identified and only those treated with an integrated approach of DG‐VLN flap and active physiotherapy were included. Outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Flap viability was evaluated through indocyanine green lymphography. Lymphedema related quality of life was evaluated preop and at 1 year follow up through LYMQOL questionnaire. Results Sixteen patients met inclusion criteria. Mean follow up was 26.2 months. Significant reduction in lower limb volume was observed for all patients from pre to post intervention. At 3 months of follow up, the mean CRR was 42.4% at below knee (BK) level and 25.4% at above knee (AK) level. At 12 months of follow up, the mean CRR was 58.3% at BK level (p = .001*) and 43.4% at AK level (p < .04*). LYMQOL metrics showed significantly better scores in all domains. Conclusions Patients with lower limb lymphedema can benefit from combined DG‐VLN flap and active physiotherapy, as this approach seem to fasten the onset of improvement and to have a positive impact on patients' quality of life.

BackgroundSuccessful vascular anastomosis is essential for the survival of free tissue transfer. The aim of the study is to review the current literature and perform a meta‐analysis to assess the potential advantages of a mechanical anastomosis coupler device (MACD) over the hand‐sewn (HS) technique for venous anastomoses.MethodsA systematic Medline search was performed to gather all reports of articles related to MACD from 1984 until now. The following data were extracted: first author and publication date, study design, number of patients and anastomosis, coupler size, site and type of reconstruction, venous anastomotic time, flap failure. A meta‐analysis was performed on articles that met the following inclusion criteria: studies comparing MACD and HS technique in venous anastomosis, reporting anastomotic time, and postoperative complications.ResultsThirty‐three studies were included for the analysis. Twenty‐four were retrospective case series and nine were retrospective comparative studies. A total of 12,304 patients were enrolled with a mean age of 49.23 years (range 31–72). A total of 13,669 flaps were accomplished. The thrombosis rate recorded with MACD was 1.47%. The meta‐analysis revealed that MACD significantly decreased anastomotic time (standard difference in means = −0.395 ± 0.105; Z = −3.776; p < .001) and postoperative flap failure risk (odds ratio [OR] = 0.362, 95% confidence interval [CI] = 0.218–0.603, Z = −3.908, p < .001), but it did not decrease postoperative venous thrombosis risk (OR = 0.504, 95% CI = 0.255–1.129, Z = −1.666, p = .096).ConclusionsMACDs are a safe and effective alternative to traditional anastomosis. The anastomotic coupler is easier, much faster, and requires less technical skills than a HS microvascular anastomosis.

Clinical applications of ALT flap have currently extended to extremity (hand and foot) as well as oral cavity reconstruction. In these anatomical areas, the traditional harvesting technique presents a few disadvantages such as bulkiness of the recipient site and potential donor site morbidity including damage to the deep fascia and skin graft adhesions. The purpose of the present study was to compare the functional and aesthetic outcomes of upper and lower extremity reconstruction with either suprafascial or subfascial harvested anterolateral (ALT) flaps. Sixty patients who underwent hand or foot reconstruction with an ALT flap between January 2013 and January 2015 were included in the study (34 flaps elevated on a subfascial plane and 26 on a suprafascial plane). Group 1 (subfascial harvested ALT flap) was composed of 23 male and 11 female patients with an average age of 53.4 years (range, 36-72 years). Group 2 (suprafascial harvested ALT flap) was composed of 18 male and 8 female patients with an average age of 48.7 years (range, 32-69 years). Surgical indication was tumor resection for 20 patients in group 1 and 16 patients in group 2, chronic ulcer for 8 patients in group 1 and 6 patients in group 2, and trauma for 6 patients in group 1 and 4 patients in group 2. Complications were documented. Aesthetic outcomes were considered in terms of bulkiness of the recipient site, subsequent request for a debulking procedure, and donor site morbidity. Donor site scars were evaluated for cosmesis using a modified Hollander Wound Evaluation Scale (HWES). Skin grafts outcomes were assessed according to the modified Vancouver Scar Scale (VSS). Functional outcome at the recipient site was measured using the Enneking functional outcome score (ESS). Total range of motion (ROM) was recorded. All flaps were successfully elevated with at least one viable perforator with both approaches. The survival rates of suprafascial and subfascial harvested ALT flaps were 96.2 and 97% respectively (P = .85). The mean flap size was 110.4 ± 27.8 cm in group 1 and 159.7 ± 44.4 cm in group 2. The average flap thickness was 26.2± 5.2 mm in group 1 and 13.9 mm ± 4.1 in group 2. Complications included total flap loss (1 case in group 1 and 1 case in group 2), partial flap loss (2 cases in group 1 and 1 case in group 2), skin graft failure (3 cases in group 1), and muscle herniation at the donor site (1 case in group 1; P < .17). Secondary debulking procedures were needed for 20 flaps in the subfascial group and for one flap in the suprafascial group (P-value <.01). Donor site closure with skin grafts was necessary in 42 cases: 32 in group 1 and 10 in group 2. The suprafascial harvested ALT flap group reported a significant difference in terms of donor site morbidity. The HWES score of donor site scars was significantly lower in group 1 (mean 1.2 ± 0.54) than in group 2 (mean 2.4 ± 0.58), P < .01. Similarly, the VSS score for skin graft outcomes was lower in patients of group 1 (mean 4.5 ± 0.93) than in patients of group 2 (mean 6.7 ± 0.96), P < ....