Pulsating Hematoma of the Thigh after Endovenous Laser Obliteration of the Great Saphenous Vein

The management of bone defects is still a difficult problem. Local vascularized bone grafts represent an efficient and widely used method. In this retrospective report, iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were used for the management of proximal femur bone defects. The hospital information system and clinical data collected by surgeons were retrospectively reviewed. Patients with massive bone defects of the proximal femur reconstructed with iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were included. Relevant data, including general information, perioperative treatment, and imaging data during follow-up, were retrieved for analysis. Five patients (4 males and 1 female) aged 18 to 42 years were included in this report. All patients were diagnosed with proximal femoral bone defects. The sizes of the bone defects ranged from 5 ×4 cm to 8 × 5 cm. Harris hip score was adopted to evaluate the functional outcomes. The adverse events were recorded. The mean follow-up time was 6.3 years. Iliac bone flaps of the ascending branch of the lateral circumflex femoral artery were transferred locally for the 5 patients. Bone flaps were fixed with plates in 4 cases and Kirschner wires in 1 case. The hospital stay was 12 to 27 days, with an average of 19.4 days. All cases achieved bony healing after 3 to 6 months postoperatively. The Harris hip scores ranged from 87 to 95 at final follow-up. All patients achieved good to excellent functional outcomes. One superficial infection occurred. No other adverse events or serious adverse events were noted. Local transfer of iliac bone flaps of the ascending branch of the lateral circumflex femoral artery represents a safe and effective method for the reconstruction of massive bone defects of the proximal femur.

Commentary: If all else fails…

Objective To explore the feasibility of three-dimensional visualizational reconstruction and virtualization simulated operation of polyfoliate perforator flap pedicled on the descending branch of the circumflex femoral lateral artery. Methods Between October, 2014 and July, 2015, a series of DICOM images were obtained from 12 patients by DSA and dual source CTA. Then the mimics 16.0 was been used to reconstruct the descending branch of the circumflex femoral lateral artery and its perforator vessels. The procedure of free polyfoliate perforator flap pedicled on the descending branch of the circumflex femoral lateral artery had been simulated in personal computer. According to design in the computer, the polyfoliate perforator flaps were designed and dissected for 12 patients who had combined with the huge or irregular wound. Results The 3D reconstruction models could provide perfectly dynamic visualization of the anatomy of the descending branch of the circumflex femoral lateral artery and clearly display three-dimensional relations of blood vessels, skin and adjacent tissue. The procedure of the free polyfoliate perforator flap transfer could be virtually simulated through the mimics soft in the personal computer. Twelve polyfoliate perforator flaps pedicled on the descending branch of the circumflex femoral lateral artery had been transfered with the methods all of flaps were successful survival and donor sites had been directly closed. All patients were followed-up with 1-5 months (mean 3.6 month). The appearance of flaps were satisfactory. Conclusion The 3D reconstruction models can provide a perfect dynamic visualization of the anatomy of the descending branch of the circumflex femoral lateral artery and its perforator vessels which can be used for individualized design of the Polyfoliate perforator flap pedicled on the descending branch of the circumflex femoral lateral artery. Key words: Circumflex femoral lateral artery; Perforator flap; Three-dimensional reconstruction; Angiography; Microsurgical operation

Antiepileptic drugs for chronic non-cancer pain in children and adolescents.

The descending branch of the lateral femoral circumflex artery is an option for coronary artery bypass grafting. To evaluate the early patency and adaptation of lumen diameter using multidetector computed angiotomography. Thirty-two patients were selected to undergo coronary artery bypass grafting using the descending branch of the lateral circumflex artery, the internal thoracic artery, and other grafts. Evaluations were carried out through high resolution computed tomography performed on the 7th and 90th postoperative day. Diameters of the descending branch of the lateral circumflex artery and the left internal thoracic artery were measured 3 cm before the distal anastomosis, in the middle portion, and 3 cm after the proximal anastomosis. Diameters were compared using paired t-test (P<0.05). Descending branch of the lateral femoral circumflex artery wDescending branch of the lateral femoral circumflex artery was used in 26 patients, as its use was not viable in six patients (18%). It was used as composite graft in all cases. The anterior descending branch was revascularized by the left internal thoracic artery in all cases. Patency rates of the descending branch of the lateral femoral circumflex artery were 96% and 92%, respectively. No occlusions were observed in the left internal thoracic artery (LITA) and no ischemic events were observed in the descending branch of the lateral circumflex. Descending branch of the lateral femoral circumflex artery increased the lumen diameter in the middle (P=0.001) and distal portions (P=0.006); the left internal thoracic artery (LITA) increased in the middle portion (P=0.001). Similar to the left internal thoracic artery, the descending branch of the lateral femoral circumflex artery showed high patency rate and positive luminal adaptation. This early evaluation confirms the descending branch of the lateral femoral circumflex artery as a potential alternative for grafting. Due to anatomical variations, preoperative femoral angiographic evaluation appears to be mandatory.

Non-thermal non-tumescent methods have been recently used in the treatment of varicose veins of the lower extremities. In particular, we talk about cyanoacrylate adhesive obliteration. However, this approach can result complications, including glue-induced thrombosis. Objective. To evaluate the incidence, risk factors and preventive measures for glue-induced thrombosis following cyanoacrylate adhesive obliteration of varicose veins of the lower extremities. Material and methods. We retrospectively analyzed electronic medical records of patients with varicose veins of the lower extremities after cyanoacrylate adhesive obliteration. The inclusion criteria were C2—C6 varicose veins with reflux &gt;0.5 s, saphenous vein diameter ≥ 6 mm. Cyanoacrylate adhesive obliteration was performed according to the protocol recommended by the manufacturer. Examination and ultrasound of lower limb veins were performed after 3 and 7 days, 1 and 3 months, 1, 3 and 5 years. Complications and adverse events, therapeutic measures and effectiveness of treatment were analyzed. Results. Medical records of 1.794 patients (2.531 lower extremities and 2.729 venous trunks) were analyzed. There were 1.179 women (65.7%) and 615 men (34.3%). Mean age of patients was 61.1±15 years. Distribution of patients by CEAP classes was as follows: C2 — 31.7%; C3 — 44.1%; C4 — 17.3%; C5 — 1.7%; C6 — 5.2%. A total of 2.729 cyanoacrylate adhesive obliteration procedures were performed. After 3 days, ultrasound verified vein occlusion in 100% of patients. The target vein occlusion rate was 95% after 1 year, 92.8% after 3 years, and 92.3% after 5 years. The long-term 5-year results were assessed in 39 patients. Glue migration with its propagation into the deep vein and glue-induced thrombosis occurred in 44 (2.5%) patients (1.6% of all interventions). Glue-induced thrombosis class I («glue crossectomy») was detected in 35 (1.9%) patients, class II in 8 (0.4%), and class III in 1 (0.05%) case. Mean thrombus retraction time for class II and III was 3—6 months. Possible risk factors of glue-induced thrombosis were intraoperative technical errors (proximal disposition of the delivery catheter at the junction area, insufficient compression of the junction area with ultrasound probe) and target vein diameter &lt; 6 mm. Conclusion. Glue-induced thrombosis is a rare complication with favorable asymptomatic course and no need for anticoagulation in the vast majority of patients.

To investigate the hemodynamics evidence of the descending branch of lateral circumflex femoral artery in a reversed way. To explore the clinical result of using the reversed descending branch of the lateral circumflex femoral artery as the receipt artery for free flaps for reconstruction of the leg soft-tissue defect. From October 2005 to February 2012, 38 patients with severe leg soft-tissue defects were treated. The proximal antegrade and retrograde mean artery pressure of the descending branch of the lateral circumflex femoral artery in 16 of 38 patients were recorded during operation. All wounds had osteomyelitis, bone and tendon exposure requiring coverage reconstruction. And there was no recipient artery in the injured lower leg for free flaps in all 38 patients. Reversed descending branches of lateral femoral circumflex arteries were used as recipient arteries for free flaps (free latissimus dorsi flap, free thoracoumbilical flap, and free anterolateral thigh flap) in all patients. The flap donor site was closed directly or with the skin graft. The proximal antegrade mean artery pressure of the descending branch of lateral circumflex femoral artery was(81.6 +/- 12.4) mmHg. The proximal retrograde pressure was(48.2 +/- 10.7) mmHg. The proximal retrograde mean artery pressure was 59.07 percent of the proximal antegrade pressure. The donor skin graft survived and wound healed primarily. After operation, 2 flaps had distal partial necrosis and healing was achieved after dressing change. All the other flaps survived completely without vascular problems. All the patients were followed up for 11 months to 2.5 years (mean, 1.6 years). The flap appearance was satisfactory. The texture and color of flaps in all cases were good. The reverse descending branch of lateral circumflex femoral artery is a reliable recipient artery for the free flaps. It is an easy and simple technique that can be used for reconstruction of the defects in the lower leg, with the reversed descending branch of lateral circumflex femoral artery as recipient artery.

Objective: To investigate the clinical effects of extra-long lateral femoral supercharged perforator flaps in repair of ankle and foot wounds. Methods: From March 2014 to October 2018, 16 patients with foot and ankle injuries were admitted to our hospital and left large area of wounds on foot and ankle after emergency treatment. There were 13 males and 3 females, with age of 27 to 60 years. The area of the wounds ranged from 14 cm×10 cm to 40 cm×17 cm. The wounds were repaired with extra-long lateral femoral supercharged perforator flaps. The widths of flaps in 8 patients were longer than 8 cm, and the bilobed flaps were designed to repair the wounds. The area of the flaps ranged from 12 cm×5 cm to 40 cm×9 cm. During the operation, 54 perforators were detected, with an average of 3.2 perforators in each flap, and 36 source arteries of perforators were detected. The blood vessel trunk of 15 patients was descending branch of the lateral femoral circumflex artery, and their supercharged mode was anastomosis of the bulky perforator of descending branch of the lateral femoral circumflex artery with the oblique branch of the lateral femoral circumflex artery and/or medial femoral circumflex artery or the descending branch of superficial illiac circumflex artery. The blood vessel trunk of 1 patient was oblique branch of the lateral femoral circumflex artery, and the supercharged mode of the patient was anastomosis of the oblique branch of the lateral femoral circumflex artery with the bulky perforator of the descending branch of the lateral femoral circumflex artery. The wounds were covered with the flaps after supercharged blood vessel anastomosis, and blood vessels in the donor sites were anastomosed with those in the recipient sites. The donor site was sutured directly. The survival of the flap after the operation and healing time of the wound, and the flap condition, the two-point discrimination distance of flap in patients who were reconstructed with sensation, the recovery of the ankle function, and the appearance of the donor site during follow-up were recorded. Results: A total of 17 flaps in 16 patients were designed, including 8 bilobed flaps and 9 non-lobulated flaps. Sixteen flaps in 15 patients survived. Vascular crisis occurred in the flap of one patient, and the flap survived when the vascular crisis was relieved by the second operation. The healing time of foot and ankle wounds ranged from 12 to 90 days. All the lateral femoral donor sites healed completely. During follow-up of 8 to 48 months, flaps in 2 patients were slightly bloated and were trimmed in 6 months after the operation. The other flaps were with good appearance, soft texture, good elasticity, and no rupture or ulceration. The two-point discrimination distances of flaps ranged from 7 to 16 mm in 8 patients who were reconstructed with sensation, and the other flaps recovered protective sensation. The flexion and extension function of ankle joint recovered well, and the walking function was not affected significantly. All donor sites formed linear scar, with no deep tissue infection such as osteomyelitis. Conclusions: The application of extra-long lateral femoral supercharged perforator flaps to repair the large area of wounds in foot and ankle can significantly reduce damage to donor sites and has advantages of rich blood supply and good safety, thus it has satisfactory clinical effects.

Sir: The lateral aspect of the thigh is an important donor site for flap harvest due to the high number of type B and C perforators suitable for pedicled and free tissue transfer. The tensor fasciae latae flap, originally described by Hill (in Plastic and Reconstructive Surgery in 1978), represents an important source of soft tissue for composite and functional reconstructions. We read with interest the article entitled “Tensor Fasciae Latae Perforator Flap: Minimizing Donor-Site Morbidity in the Treatment of Trochanteric Pressure Sores,”1 in which the authors recognized the ascending branch of the circumflex femoral artery as the unique source of vascularization of the tensor fasciae latae muscle in 100 percent of the dissected legs. We performed a review of the related literature using plastic surgical journals and PubMed as the main sources of information. Among these articles, we found an important discordance about the identification of the main source of this muscle. Koshima et al.2 described the transverse branch of the lateral circumflex femoral system as the primary vascular supply of the tensor fasciae latae muscle; Kimura,3 in agreement with Ishida et al.,1 recognized the ascending branch of the lateral circumflex femoral artery as the main source of the muscle. Rifaat and Abdel Gawad,4 in accordance with Koshima et al.,2 found the transverse branch of the circumflex femoral artery to be the main source of all of their flaps (n = 12). In an ongoing cadaveric dissection study, we have dissected 31 lower limbs injected with latex. We found the tensor fasciae latae muscle to be supplied in 74 percent from the ascending branch of the lateral circumflex femoral artery and in 13 percent of the sites from the transverse branch of the lateral circumflex femoral artery; in another 13 percent, the artery supplying the tensor fasciae latae was found to arise directly from the common femoral artery or from the deep femoral artery. In four thighs we noticed a secondary arterial supply nourishing the tensor fasciae latae muscle by arising from either the ascending or the descending branch or directly from the femoral artery (Fig. 1).Fig. 1.: Left side of the groin of an injected cadaver in which the source vessels to the tensor fasciae latae have been dissected. F.V., femoral vein; F.A., femoral artery; A.B., ascending branch of the lateral circumflex femoral artery; arrow, secondary source from the femoral artery.The variability about the origin and branching pattern of the lateral circumflex femoral artery has already been reported.5 The aim of this short report about the main source of the tensor fasciae latae flap (as a muscular, musculocutaneous, or perforator flap) is to invite surgeons to exercise caution during the deep dissection of the pedicle, as its vascular supply presents a higher variability than previously reported. Stefano Cotrufo, M.D. Joerg Dabernig, M.D. Canniesburn Plastic Surgery Unit Glasgow Royal Infirmary Glasgow, United Kingdom Integrated Biological and Life Sciences Section for Human Anatomy University of Glasgow Glasgow, United Kingdom Department of Surgical and Perioperative Science Section for Hand and Plastic Surgery University Hospital Umea, Sweden Department of Integrative Medical Biology Section for Anatomy Umea University Umea, Sweden ACKNOWLEDGMENT This research was sustained by the Steven Forrest Charitable Trust.

Several recipient vessels can be used in free microsurgical fibula flaps (MFFs) for the treatment of avascular necrosis of the femoral head (ANFH). Few articles investigate the influence of different recipient vessels on outcomes of MFF for ANFH. A comprehensive literature search of databases including PubMed-Medline, Ovid-Embase, and Cochrane Library was performed to collect the related studies. The Medical Subject Headings used were "femur head necrosis" and "bone transplantation." The relevant words in title or abstract included but not limited to "fibula flap," "fibular flap," "vascularized fibula," "vascularized fibular," "free fibula," "free fibular," "femoral head necrosis," "avascular necrosis of femoral head," and "ischemic necrosis of femoral head." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Finally, 15 studies encompassing a total of 1267 patients (1603 hips) with ANFH were pooled in the overall analysis. Recipient vessels for MFF included the ascending branch of the lateral circumflex femoral artery and vein in 8 studies, descending branch of the lateral circumflex femoral artery and vein in 2 studies, second perforating branch of the deep femoral artery and vein in 4 studies, and inferior gluteal artery and vein in 1 study. Preoperative and postoperative average Harris hip score and pooled analyses of the rate of conversion, radiographic progression, and hip surgery-related complications showed no significant difference on the outcomes of MFF on ANFH between using different recipient vessels. Different recipient vessels did not affect outcomes in MFF procedures for ANFH. High-quality randomized controlled trials and prospective studies would be necessary to clarify reliable advantages and disadvantages between different recipient vessels. Until then, surgeons are justified in using ascending branch of the lateral circumflex femoral artery and vein, descending branch of the lateral circumflex femoral artery and vein, second perforating branch of the deep femoral artery and vein, and inferior gluteal artery and vein vessels according to care circumstances and customary practice.

Objective To reconstruct soft tissue defect of the elbow combined with brachial artery injury using anterolateral thigh flap that used the transverse branch of the lateral femoral circumflex artery as the vessel pedicle, and evaluate the clinical results. Methods Eight cases of brachial artery injury along with soft tissue defect at the elbow were treated between March 2000 and February 2008. Primary repair of the tissue defect was done by free transfer of the anterolateral thigh flap using the transverse branch of the lateral femoral circumflex artery as the vessel pedicle. The transverse branch of the lateral femoral circumflex artery was simultaneously inserted between the two ends of the injured brachial artery (3 to 7 cm defect). The areas of the skin defect ranged from 12 cm×6 cm to 20 cm×10 cm. Results Limbs and flaps of the 8 cases all survived. Postoperative follow up ranged from 10 months to 21 months. There were no obvious bulkiness and scar contracture of the tlaps. The average ROM of the elbows was 105°(95° to 125°). In all 8 cases, the pulse strength of the distal ulnar and radial arteries was the same as that of the uninjured side. Ultrasound detection of the brachial artery revealed blood flow of the injured side similar to that of at the uninjured fide. Conclusion When there exists vascular variation of the descending branch of the lateral femoral circumflex artery during dissection of the anterolateral thigh flap, the transverse branch of the hteral femoral circumflex artery can be used as the vessel pedicle of the flap. Made as a flow-through flap, this flap can be transferred to recommit soft tissue defects of the elbow combined with brachial artery defect. Key words: Wounds and injuries; Brachial artery; Surgical flans; Microsurgery

Sir: Having a wide range of applications, the anterolateral thigh flap has almost been the most representative soft tissue with minimal donor-site morbidity.1 Most important of all, with the vascular pedicle mostly arising from the descending branch of the lateral circumflex femoral artery, it can offer a sufficient length for microanastomosis to recipient vessels, especially in the field of head and neck reconstruction. Nevertheless, the complexity of the local vasculature of the anterolateral thigh flap has been well documented. Several studies have pointed out the possibility of no sizable perforators, even with Doppler vascular mapping preoperatively. Also, microsurgeons may need a backup procedure or an alternative.2 In addition, a substantial number of reported variations concerning the lateral circumflex femoral artery plus its branches emphasize the unpredictability of the perforators’ origin. If the only sizable perforator arises from the proximal thigh, it can only provide pedicle length that is less than 10 cm.3 The patient, a 42-year-old man, had been diagnosed with secondary right maxillary squamous cell carcinoma. Due to previous flap surgery, preoperative angiography was performed and only left-side neck vessels were relatively available for the recipient site. The desired pedicle length was determined to be 18 to 20 cm from the right-side upper face to the left superior thyroid artery and external jugular vein. A planned right anterolateral thigh flap was dissected. Nonetheless, the only sizable perforator that could be found was located at 7 cm proximal to the midpoint of the thigh. The perforator retrogradely originated from the oblique branch of the lateral circumflex femoral artery. The pedicle was estimated to be only 6 cm. In order to elongate the pedicle of the anterolateral thigh flap, the perforator was traced to the very beginning of the oblique branch and cut without influencing the blood flow of the descending branch of the lateral circumflex femoral artery. In addition, the descending branch was dissected to the most distal part as a vascular bundle bridge. Without separating the flap in advance, a one-artery and two-venae comitantes anastomosis was performed in situ of the anterolateral thigh incision wound (Fig. 1; Fig. 2, left and center). Utilizing this innovative method, we effectively elongated the pedicle from 6 cm to 18 cm (Fig. 2, right). Without sacrificing any other tissue or incising any other wound for vascular grafts, we successfully lengthened the pedicle of the anterolateral thigh flap and overcame the problems (Fig. 3). No complications were encountered postoperatively, and the flap survived completely.Fig. 1: In situ lengthening of the anterolateral thigh flap pedicle. The original pedicle length is supposed to be (a + c). After dissection of the descending branch of the lateral circumflex femoral artery (b) and performing the new one-artery and two-venae comitantes anastomosis, the pedicle is elongated to (a+ b + c) without extra flap ischemic time.Fig. 2: (Left) Dissecting and identifying the sizable anterolateral thigh perforator originating from the oblique branch of the lateral circumflex femoral artery. Dissecting the descending branch to the most distal part. (Center) In situ anastmosis of the most proximal part of the perforator to the most distal part of the descending branch of the lateral circumflex femoral artery. (Right) The pedicle in situ is successfully lengthened from 6 cm to 18 cm without any extra flap ischemic time.Fig. 3: The pedicle was successfully anastomosed from the right maxillary area to the left lower neck area.Even though the vein graft interposition is a traditionally accepted pedicle bridging technique for microvascular reconstruction, vein grafting of the head and neck free flap reconstruction has rarely been addressed and might have higher failure rates.4 To avoid merely vein grafting, numerous studies have reported harvesting the descending branch of the lateral circumflex vessels for vascular bundle bridging.5 These reports offer the advantage of equal-caliber vessels with adequate length that are not critical to the blood supply of the leg. At this point, we emphasize an “in situ” elongation of the pedicle without consuming extra flap ischemic time. This idea is worth offering as an alternative solution for insufficient anterolateral thigh pedicles. ACKNOWLEDGMENT Special thanks go to Sang-Ju Lin for her assistance in correcting the article’s grammar. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Yu-Hao Huang, M.D. Tung-Ying Hsieh, M.D. Chung-Sheng Lai, M.D., Ph.D. Sin-Daw Lin, M.D. Kao-Ping Chang, M.D., Ph.D. Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan

Most renal injuries in pediatric patients are treated conservatively, but prolonged hematuria and major blood vessel injuries often require active bleeding control. Traumatic pseudoaneurysms of segmental branches of the renal artery occur in 2.5% of renal injuries. They usually manifest as prolonged or intermittent secondary hematuria, but may be asymptomatic as well. Watchful waiting is the initial treatment, and around one third of patients eventually require active surgical or endovascular treatment. The two main endovascular coil embolisation methods are the “sandwich” and the “coil packing” technique, but occlusion using a stent is also possible. Traumatic prolonged hematuria caused by pseudoaneurysm of the renal segmental arterial branch, and the methods of treatment are rarely reported, especially in children. This report presents a boy in whom a blunt kidney injury lead to the formation of a pseudoaneurysm of the renal segmental arterial branch, causing prolonged hematuria. The patient was treated by endovascular embolisation through the right femoral artery, in local anesthesia and conscious sedation. A 2.7 Fr microcatheter was used to selectively enter the dominant cranial renal artery and show the pseudoaneurysm of a segmental interlobar arterial branch. A 2×4 mm coil was used to occlude the segmental interlobar arterial branch and pseudoaneurysm, with no post-procedural bleeding or significant renal segmental ischemia. Endovascular treatment offers advantages over open surgery, but has certain drawbacks as well, such as high radiation and contrast exposure. In the last few years, a minimally invasive robotic surgical procedure has been described for the treatment of intra-renal pseudoanurysm. The current worldwide trend in pediatric renal injuries treatment is the reduction in the number of nephrectomies, and a shift to non-operative and minimally invasive treatment, including endovascular procedures. University Hospital Centre Zagreb has all the specialities and capacities required for surgical and endovascular procedures in children, making it the national referral centre for pediatric renal injuries treatment.

No. 125 Endovascular versus percutaneous treatment of pancreatic pseudoaneurysms

Sir: The technological advancements in microsurgical devices and instruments allow microsurgeons to perform any type of microsurgery in a feasible and safe manner. Specifically, the operating microscope has been improved upon in many aspects, including resolution of the visual field and even a three-dimensional monitoring system.1 Despite such advances in operating microscopes, a few concerns remain, such as their large and heavy build, limited visual field through the ocular lens (resulting in neck stiffness for the surgeons), and the physical discomfort for the assistant, since this completely depends on the physical position taken by the principal surgeons. The three-dimensional exoscope was first introduced in the field of neurosurgery. Oertel and Burkhardt2 described their consecutive cases of five cranial and 11 spinal procedures using the Vitom-3D exoscope (Karl Storz, GmbH, Tuttlingen, Germany), without any adverse events. Recently, the first successful case of microvascular anastomosis with the Vitom-3D exoscope, in a free deep inferior epigastric perforator flap for breast reconstruction, was reported by Piatkowski et al.3 However, their article provides only snapshot images, which make it difficult to understand how a three-dimensional exoscope seems useful. We tested the Vitom-3D exoscope in two cases for head and neck reconstruction with a free anterolateral thigh flap transfer. (Use of the Vitom-3D exoscope for the first case on August 8, 2018, was approved by the Institutional Review Board of Juntendo University Hospital.) In the first case, a 69-year-old woman who had previously undergone posterior craniotomy experienced delayed wound infection and subsequent cranial exposure. After débridement and dissection of the ipsilateral facial artery and vein under the exoscope, the descending branch of the lateral femoral circumflex artery and vein were anastomosed to the recipient vessels in an end-to-end fashion (Fig. 1). In the second case, a 71-year-old man who had undergone mesopharyngectomy due to mesopharyngeal cancer subsequently underwent reconstruction with a free anterolateral thigh flap. The superior thyroid artery and internal jugular vein were selected as recipient vessels and anastomosed with the descending branch of the lateral femoral circumflex artery and vein in an end-to-end and end-to-side fashion, respectively (Fig. 2). [See Video 1 (online), which shows a demonstration of the overview of the Vitom-3D exoscope. See Video 2 (online), which demonstrates an end-to-side venous anastomosis.] Neither of these cases had complications, including vascular thrombosis and flap necrosis. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"Overview of the vascular preparation for microvascular anastomosis using the three-dimensional exoscope. In this video, the principal surgeon makes a vascular window to the internal jugular vein as a recipient vein for end-to-side anastomosis.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_y428epmn"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"Monitor view of the end-to-side venous anastomosis. The comitant vein of the descending branch of the lateral circumflex femoral artery and internal jugular vein are anastomosed with 9-0 nylon in an end-to-side fashion.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_64vgfest"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fig. 1.: Overview of the Vitom-3D exoscope. Compared with the standard surgical microscope, the body is light and easy to set up. In addition, the three-dimensional wide-view monitor with 4K resolution provides a clear surgical field.Fig. 2.: Overview of microvascular anastomosis under the three-dimensional exoscope. The principal operator and assistant surgeon are sitting in an oblique, face-to-face position (approximately 150 degrees to each other).The Vitom-3D exoscope has several advantages compared to the standard surgical microscope. First, the three-dimensional wide view with 4K resolution can be obtained during the microsurgery, which allows any surgeon to deal with tiny vessels precisely and less traumatically. Second, the principal operator and assistant surgeon can be independent and not interfere with one another during the surgery, since they can watch the monitor independently. Finally, the exoscope helps to further the learning curve for residents in terms of training in microsurgery, as well as in recent reports of virtual reality.4 The trainer, trainees, and even observers can watch the same monitor simultaneously during microsurgical training and easily share technical skills and valuable tips. [See Figure, Supplemental Digital Content 1, demonstrating an overview of microsurgery training using the three-dimensional exoscope. The trainee practices microvascular anastomosis using an artificial microvessel under the guidance of the trainer, while both trainer and trainee watch the same monitor side-by-side. (Left) Anterior view; (right) posterior view, https://links.lww.com/PRS/D725.] In conclusion, the three-dimensional exoscope may be a promising device in the field of reconstructive microsurgery. DISCLOSURE The authors have no financial disclosures to report. Yuichi Ichikawa, M.D.Daiki Senda, M.D.Yoshiaki Shingyochi, M.D., Ph.D.Hiroshi Mizuno, M.D., Ph.D.Department of Plastic and Reconstructive SurgeryJuntendo University School of MedicineTokyo, Japan