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Sun JM, Yamamoto T. Genital elephantiasis: Surgical treatment and reconstruction. J Chin Med Assoc 2024; 87:142-147. [PMID: 37962359 DOI: 10.1097/jcma.0000000000001021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
Genital elephantiasis is a severe form of lymphedema of the groin. It is characterized by progressive enlargement and distortion of the genitals, presenting significant physical, psychological, and social challenges to the affected individuals. Although pharmacological treatment of filariasis is well-established in the medical field, the surgical management of genital elephantiasis can be varied and confusing. This review article provides an in-depth analysis of the etiology, classification, severity grading, and various effective surgical treatment and reconstructive modalities commonly employed by surgeons since the early twentieth century. We also discuss how a combination approach of ablation, soft tissue coverage, and lymphatic reconstruction is viable for treating genital elephantiasis. By examining the literature, we hope to provide insights into how surgery plays a role in the holistic management of genital elephantiasis.
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Affiliation(s)
- Jeremy Mingfa Sun
- Department of Surgery, Plastic Reconstructive and Aesthetic Surgery Service, Changi General Hospital, Singapore
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
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Dionyssiou D, Nguyen D, Topalis A, Deptula P, Paukshto M, Zaitseva T, Demiri E, Cheva A, Rockson S. Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds. J Reconstr Microsurg 2024; 40:145-155. [PMID: 37142251 DOI: 10.1055/a-2086-0269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model. METHODS Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline. RESULTS Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A. CONCLUSION The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.
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Affiliation(s)
- Dimitrios Dionyssiou
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | - Anastasios Topalis
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Peter Deptula
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Efterpi Demiri
- Department of Plastic Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Angeliki Cheva
- Laboratory of Pathology, Medical School, Aristotle University, Thessaloniki, Greece
| | - Stanley Rockson
- Center for Lymphatic and Venous Disorders, Stanford University School of Medicine, Stanford, California
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Drobot D, Leitner Shemy O, Zeltzer AA. Biomaterials in the clinical treatment of lymphedema-a systematic review. J Vasc Surg Venous Lymphat Disord 2024; 12:101676. [PMID: 37696416 DOI: 10.1016/j.jvsv.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE Lymphedema is a chronic condition caused by impaired lymphatic fluid drainage, resulting in progressive edema. The current mainstay of lymphedema therapy consists of conservative therapy and surgical therapy. In this systematic review, we investigated the novel role of biomaterials in clinical lymphedema therapy and assessed their objective outcomes and the complication rate associated with their use. METHODS Studies were identified through systematic review using the Embase and PubMed/MEDLINE databases. Only original articles reporting the use of biomaterials for clinical lymphedema therapy were included. The primary outcome measure was the objective reduction in limb volume after biomaterial use. The secondary outcome measure was the assessment of biomaterial safety. RESULTS A total of 354 articles were identified in the first search, of which 10 met our inclusion criteria. These articles described the use of two biomaterials, nanofibrillar collagen scaffolds (NCSs) and silicone tubes (STs), for the treatment of lymphedema. NCS implantation showed an average excess limb volume reduction of 1% to 10.7% and clear evidence of lymphangiogenesis on imaging. No complications were 7documented after NCS implantation. ST implantation showed an average limb volume reduction of 700 to 887 mL and limb circumference reduction of 3.1 to 8 cm in patients with advanced stage lymphedema. Of 177 patients treated with ST implantation, only 11 (6.2%) developed local inflammation. CONCLUSIONS Both NCS and ST implantation showed promising limb volume reduction; however, with the scarce literature available, additional research is needed to determine their effectiveness. Both demonstrated good safety profiles, with no complications after NCS implantation and a complication rate equivalent to other similar implants for ST implantation.
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Affiliation(s)
- Denis Drobot
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ortal Leitner Shemy
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Assaf Aviram Zeltzer
- Department of Plastic and Reconstructive Surgery, Rambam Health Care Campus, Haifa, Israel; Bruce and Ruth Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.
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Singh K, Kania T, Kimyaghalam A, Breier Y, Cooper M. How I do it: Radical debulking of lower extremity end-stage lymphedema. J Vasc Surg Cases Innov Tech 2023; 9:101238. [PMID: 37520169 PMCID: PMC10372319 DOI: 10.1016/j.jvscit.2023.101238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/20/2023] [Indexed: 08/01/2023] Open
Abstract
Debulking procedures have been a last-resort therapy for end-stage lymphedema for more than a century. Multiple techniques have been described, and the approach as a whole has fallen in and out of favor as providers have tried to maximize quality of life outcomes. We describe our technique for radical debulking of the lower extremity for the treatment of severe end-stage lymphedema.
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Affiliation(s)
- Kuldeep Singh
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital, Staten Island, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Thomas Kania
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital, Staten Island, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Ali Kimyaghalam
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital, Staten Island, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Yuli Breier
- Touro College of Osteopathic Medicine, Harlem, NY
| | - Michael Cooper
- Division of Vascular and Endovascular Surgery, Staten Island University Hospital, Staten Island, NY
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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Kaya B, Tang YB, Chen SH, Chen HC. Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema. Asian J Surg 2023; 46:794-800. [PMID: 35850907 DOI: 10.1016/j.asjsur.2022.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/21/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated. METHODS Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10). RESULTS In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later. CONCLUSION To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.
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Affiliation(s)
- Burak Kaya
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara University Faculty of Medicine, Ankara, Turkey; Ankara University Medical Design Application and Research Center (MEDITAM), Ankara, Turkey; China Medical University and China Medical University Hospital, Taichung, Taiwan
| | - Yueh-Bih Tang
- Department of Plastic Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung University and Medical Collage, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Chi Chen
- China Medical University and China Medical University Hospital, Taichung, Taiwan.
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Seth I, Bulloch G, Gibson D, Seth N, Hunter-Smith DJ, Rozen WM. Quantification and Effectiveness of Vascularized Neck Lymph Node Transfer for Lymphedema: a Systematic Review and Meta-Analysis. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276:635-653. [PMID: 35837897 PMCID: PMC9463125 DOI: 10.1097/sla.0000000000005591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. METHODS This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. CONCLUSIONS VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
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Affiliation(s)
- Stav Brown
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Knackstedt R, Chen WF. Current Concepts in Surgical Management of Lymphedema. Phys Med Rehabil Clin N Am 2022; 33:885-899. [DOI: 10.1016/j.pmr.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Viviano SL, Neligan PC. Updates on Excisional Procedures for Lymphedema. Adv Wound Care (New Rochelle) 2022; 11:419-427. [PMID: 34128393 DOI: 10.1089/wound.2021.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Significance: Excisional procedures for lymphedema have been used for over a century, and many surgeons have abandoned the old techniques as improvements in nonsurgical management and microsurgery have limited their clinical utility. Nonetheless, excisional procedures remain relevant as an important tool in the comprehensive surgical management of lymphedema. Recent Advances: Modifications to the Charles procedure and other direct excisional procedures have improved the complication profile and patient outcomes. Moreover, the use of liposuction techniques for minimally invasive tissue excision has expanded the scope of excisional surgery to benefit patients with less severe lymphedema. Recent operations combining excisional and physiologic procedures may prove to have superior results to stand-alone procedures. Critical Issues: No standard protocol exists for the comprehensive surgical management of lymphedema. Proper patient selection for any procedure requires robust outpatient assessment, cooperation with physiotherapy treatment teams, careful patient stratification, and a clear understanding of the procedure's goal. Future Directions: Larger, prospective trials will be needed to elucidate the ideal timing and combinations of techniques to optimize outcomes for patients with late-stage lymphedema.
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Affiliation(s)
- Stephen L Viviano
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Peter C Neligan
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review. Medicina (B Aires) 2022; 58:medicina58070954. [PMID: 35888673 PMCID: PMC9324426 DOI: 10.3390/medicina58070954] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.
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Ciudad P, Escandón JM, Manrique OJ, Bustos VP. Lessons Learnt from an 11-year Experience with Lymphatic Surgery and a Systematic Review of Reported Complications: Technical Considerations to Reduce Morbidity. Arch Plast Surg 2022; 49:227-239. [PMID: 35832669 PMCID: PMC9045509 DOI: 10.1055/s-0042-1744412] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Complications experienced during lymphatic surgery have not been ubiquitously reported, and little has been described regarding how to prevent them. We present a review of complications reported during the surgical management of lymphedema and our experience with technical considerations to reduce morbidity from lymphatic surgery. A comprehensive search across different databases was conducted through November 2020. Based on the complications identified, we discussed the best approach for reducing the incidence of complications during lymphatic surgery based on our experience. The most common complications reported following lymphovenous anastomosis were re-exploration of the anastomosis, venous reflux, and surgical site infection. The most common complications using groin vascularized lymph node transfer (VLNT), submental VLNT, lateral thoracic VLNT, and supraclavicular VLNT included delayed wound healing, seroma and hematoma formation, lymphatic fluid leakage, iatrogenic lymphedema, soft-tissue infection, venous congestion, marginal nerve pseudoparalysis, and partial flap loss. Regarding intra-abdominal lymph node flaps, incisional hernia, hematoma, lymphatic fluid leakage, and postoperative ileus were commonly reported. Following suction-assisted lipectomy, significant blood loss and transient paresthesia were frequently reported. The reported complications of excisional procedures included soft-tissue infections, seroma and hematoma formation, skin-graft loss, significant blood loss, and minor skin flap necrosis. Evidently, lymphedema continues to represent a challenging condition; however, thorough patient selection, compliance with physiotherapy, and an experienced surgeon with adequate understanding of the lymphatic system can help maximize the safety of lymphatic surgery.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
- Academic Department of Surgery, School of Medicine Hipolito Unanue, Federico Villarreal National University, Lima, Perú
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Valeria P. Bustos
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical University, Boston, Massachusetts
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Hayashi A, Visconti G, Yang CS(J, Hayashi N, Yoshimatsu H. Additional Lymphaticovenular Anastomosis on the Posterior Side for Treatment of Primary Lower Extremity Lymphedema. J Clin Med 2022; 11:jcm11030867. [PMID: 35160317 PMCID: PMC8836829 DOI: 10.3390/jcm11030867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 02/02/2022] [Indexed: 02/01/2023] Open
Abstract
The efficacy of lymphaticovenular anastomosis (LVA) for the treatment of primary lymphedema has been reported. Previous research suggested the efficacy of LVA on the anterior side of the lower limb, but no research has yet underlined the effectiveness of LVA on the posterior side. In the present study, we aimed to investigate the efficacy of LVA on the posterior side of the lower leg for treatment of primary lymphedema, i.e., whether further improvement of primary lower extremity lymphedema could be expected by performing LVA on the posterior side of the lower limb in addition to the LVA on the anterior side, which is usually performed. Forty-five patients with primary lower extremity lymphedema who underwent LVA twice between March 2018 and September 2020 were retrospectively investigated. Patients were classified into two groups: those who underwent LVA on the posterior side in the second operation (PoLVA group) and those who underwent LVA on the medial and anterior sides again in the second operation (MeLVA group). All patients underwent LVA on the medial and anterior sides in the first operation, but no sufficient improvement was observed. The following factors in the second operation were compared between the two groups: skin incision length, the number of anastomoses, the diameters of the lymphatic vessels, the time required for the dissection of the lymphatic vessels and veins and the reduction in volume. LVA resulted in 227 anastomoses (106 anastomoses in the PoLVA group and 121 anastomoses in the MeLVA group) in 26 patients with primary lymphedema of the lower extremities in two surgeries. The reduction in lower extremity lymphedema index was significantly greater in the PoLVA group than that in the MeLVA group (10.5 ± 4.5 vs. 5.5 ± 3.6; p = 0.008), and the number of anastomoses in the PoLVA group was significantly lower than that in the MeLVA group (3.5 ± 0.6 vs. 4.6 ± 1.0; p = 0.038). LVA on the posterior side subsequent to LVA on the medial and anterior sides resulted in the further improvement of primary lower extremity lymphedema with fewer numbers of anastomoses.
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Affiliation(s)
- Akitatsu Hayashi
- Department of Lymphedema Center, Kameda General Hospital, Chiba 296-0041, Japan
- Correspondence: ; Tel.: +81-470-92-2211 (ext. 6150)
| | - Giuseppe Visconti
- Department of Plastic and Reconstructive Surgery, Università Cattolica del “Sacro Cuore”, University Hospital “A. Gemelli”, Rome 00168, Italy;
| | - Chia-Shen (Johnson) Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 83301, Taiwan;
| | | | - Hidehiko Yoshimatsu
- Department of Plastic Surgery, Cancer Institute Hospital of the JFCR, Tokyo 135-0063, Japan;
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The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up. J Clin Med 2022; 11:jcm11030570. [PMID: 35160022 PMCID: PMC8836833 DOI: 10.3390/jcm11030570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.
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Management of Lymphoedema in Breast Cancer. Breast Cancer 2022. [DOI: 10.1007/978-981-16-4546-4_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Retrograde Manual Lymphatic Drainage following Vascularized Lymph Node Transfer to Distal Recipient Sites for Extremity Lymphedema: A Retrospective Study and Literature Review. Plast Reconstr Surg 2021; 148:425e-436e. [PMID: 34432699 DOI: 10.1097/prs.0000000000008252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascularized lymph node transfer is an efficacious treatment for extremity lymphedema. This study investigated the outcome of retrograde manual lymphatic drainage for vascularized lymph node transfer to distal recipient sites. METHODS Lymphedema patients who underwent either complete decongestive therapy or vascularized lymph node transfer between 2013 and 2018 were retrospectively included. Retrograde manual lymphatic drainage was started with intermittent manual compression and the assistance of a sphygmomanometer and proximal-to-distal massage of the limb 1 month postoperatively. Outcomes evaluations used the circumferential reduction rate and the Lymphedema-Specific Quality-of-Life Questionnaire. Outcomes of vascularized lymph node transfer to proximal versus distal recipient sites in the literature between 2006 and 2018 were also compared. RESULTS One hundred thirty-eight unilateral extremity lymphedema patients, including 68 patients in the complete decongestive therapy group and 70 patients in the vascularized lymph node transfer group, were included. The mean circumferential reduction rate of 38.9 ± 2.5 percent in the vascularized lymph node transfer group was statistically greater than the 13.2 ± 10.1 percent rate in the complete decongestive therapy group (p = 0.01). At a mean follow-up of 36 months, the improvement of overall Lymphedema-Specific Quality-of-Life Questionnaire score from 3.8 ± 0.3 to 7.5 ± 1.8 in the vascularized lymph node transfer group was statistically greater than that in the complete decongestive therapy group (from 4.7 ± 0.9 to 5.0 ± 1.9; p < 0.01). In total, 536 lymphedema patients who underwent 548 vascularized lymph node transfers in 23 published articles were reviewed; the distal recipient-site group was found to have more efficacious results than the proximal recipient-site group. CONCLUSION Vascularized lymph node transfer to a distal recipient site with standard retrograde manual lymphatic drainage significantly improved circumferential reduction rates and Lymphedema-Specific Quality-of-Life Questionnaire scores. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Yang JCS, Wu SC, Hayashi A, Lin WC, Huang GK, Tsai PY, Chien PC, Hsieh CH. Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction-A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10143121. [PMID: 34300287 PMCID: PMC8305302 DOI: 10.3390/jcm10143121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 12/17/2022] Open
Abstract
Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.
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Affiliation(s)
- Johnson Chia-Shen Yang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-7-7317123 (ext. 8002)
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan;
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Akitatsu Hayashi
- Department of Lymphedema Center, Kameda General Hospital, Chiba 296-0041, Japan;
| | - Wei-Che Lin
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Diagnostic Radiology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Gong-Kai Huang
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
- Department of Pathology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan
| | - Pei-Yu Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Peng-Chen Chien
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
| | - Ching-Hua Hsieh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833253, Taiwan; (P.-Y.T.); (P.-C.C.); (C.-H.H.)
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; (W.-C.L.); (G.-K.H.)
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Chen SH, Cem Yildirim ME, Mousavi SA, Chen HC. Long-term functional outcomes upon application of split-thickness skin graft around major joints in HCC (Hung-Chi Chen)-modified Charles’ procedure for advanced lymphedema. Asian J Surg 2021; 44:169-173. [DOI: 10.1016/j.asjsur.2020.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/21/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022] Open
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Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature. J Plast Reconstr Aesthet Surg 2020; 74:540-548. [PMID: 33248939 DOI: 10.1016/j.bjps.2020.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/23/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate. MATERIALS AND METHODS A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap). RESULTS Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p < 0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series. CONCLUSIONS Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.
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Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
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20
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Yildirim MEC, Chen SH, Weng HC, Mousavi SA, Chen HC. Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema. J Plast Reconstr Aesthet Surg 2020; 74:168-173. [PMID: 32900654 DOI: 10.1016/j.bjps.2020.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/02/2020] [Accepted: 08/01/2020] [Indexed: 11/17/2022]
Abstract
The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.
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Affiliation(s)
| | - Shih-Heng Chen
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
| | - Hui-Ching Weng
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | | | - Hung Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.
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22
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Kaya B, Ciudad P, Chen SH, Para L, Chen HC. Technical details for harvesting gastro-epiploic lymph node flaps via mini-laparotomy incision. J Plast Reconstr Aesthet Surg 2020; 73:1630-1636. [PMID: 32475737 DOI: 10.1016/j.bjps.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/08/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
Laparoscopic harvest method to obtain gastro-epiploic lymph node flaps for lymphedema treatment has been previously described. In this article, the technical details of an alternative method - open approach via mini-laparotomy incision - for harvesting gastro-epiploic lymph node flaps and preparation of the flaps for the inset is presented. A total of 17 patients were included in this series of the mini-laparotomy approach. Blood loss was minimal during the surgery. The average duration of lymph node flap harvest was 65 min. The average length of hospital stay was 10 days. The period of the restricted diet was 1.5 days. The upper abdominal scar was acceptable, there were no postoperative hernia or bulging, and there were no complications related to bowel obstruction during the follow-up. The open approach harvest method via mini-laparotomy incision offers similar results to laparoscopic harvest method, and it is safe when applied with the right technique.
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Affiliation(s)
- Burak Kaya
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan; Ankara University Faculty of Medicine, Ankara, Turkey
| | - Pedro Ciudad
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | | | - Luis Para
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan.
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23
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Park KE, Allam O, Chandler L, Mozzafari MA, Ly C, Lu X, Persing JA. Surgical management of lymphedema: a review of current literature. Gland Surg 2020; 9:503-511. [PMID: 32420285 DOI: 10.21037/gs.2020.03.14] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Lymphedema may be characterized by a progressive clinical course and limitations in improvement despite multi-modality treatment. In westernized countries, it most commonly presents as an undesirable complication of cancer treatment, particularly breast cancer. In the past several decades, surgical treatments for lymphedema have advanced, alongside developments in microsurgery. Lymphovenous anastomosis (LVA) and lymph node transplantation are physiological therapies that may reduce lymphedema through addressing its route cause. Ablative techniques such as liposuction and subcutaneous excision aid in resolving the accumulation of proteinaceous adipose and fibrotic tissue seen in advanced lymphedema. The goal of this review is to examine the outcomes and limitations of current surgical techniques used in lymphedema management.
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Affiliation(s)
- Kitae E Park
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Omar Allam
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ludmila Chandler
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad Ali Mozzafari
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Catherine Ly
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - John A Persing
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
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Ciudad P, Manrique OJ, Bustos SS, Coca JJP, Chang C, Shih P, Nicoli F, Lo Torto F, Agko M, Huang TC, Maruccia M, Chen H. Comparisons in long‐term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery 2020; 40:130-136. [DOI: 10.1002/micr.30508] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 08/08/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Samyd S. Bustos
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - John J. P. Coca
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
| | - Chang‐Cheng Chang
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Pin‐Keng Shih
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive SurgeryUniversity of Rome “Tor Vergata” Rome Italy
| | - Federico Lo Torto
- Sapienza Università di Roma, Policlinico Umberto I, Department of Surgery “P. Valdoni”Unit of Plastic Reconstructive and Aesthetic Surgery Rome Italy
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Tony C.‐T. Huang
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
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25
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A Pre-clinical Animal Model of Secondary Head and Neck Lymphedema. Sci Rep 2019; 9:18264. [PMID: 31797883 PMCID: PMC6892928 DOI: 10.1038/s41598-019-54201-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/04/2019] [Indexed: 12/30/2022] Open
Abstract
Head and neck lymphedema (HNL) is a disfiguring disease affecting over 90% of patients treated for head and neck cancer. Animal models of lymphedema are used to test pharmacologic and microsurgical therapies; however, no animal model for HNL is described in the literature to date. In this study we describe the first reproducible rat model for HNL. Animals were subjected to two surgical protocols: (1) lymphadenectomy plus irradiation; and (2) sham surgery and no irradiation. Head and neck expansion was measured on post-operative days 15, 30 and 60. Magnetic resonance imaging (MRI) was acquired at the same time points. Lymphatic drainage was measured at day 60 via indocyanine green (ICG) lymphography, after which animals were sacrificed for histological analysis. Postsurgical lymphedema was observed 100% of the time. Compared to sham-operated animals, lymphadenectomy animals experienced significantly more head and neck swelling at all timepoints (P < 0.01). Lymphadenectomy animals had significantly slower lymphatic drainage for 6 days post-ICG injection (P < 0.05). Histological analysis of lymphadenectomy animals revealed 83% greater subcutis thickness (P = 0.008), 22% greater collagen deposition (P = 0.001), 110% greater TGFβ1+ cell density (P = 0.04), 1.7-fold increase in TGFβ1 mRNA expression (P = 0.03), and 114% greater T-cell infiltration (P = 0.005) compared to sham-operated animals. In conclusion, animals subjected to complete lymph node dissection and irradiation developed changes consistent with human clinical postsurgical HNL. This was evidenced by significant increase in all head and neck measurements, slower lymphatic drainage, subcutaneous tissue expansion, increased fibrosis, and increased inflammation compared to sham-operated animals.
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Watanabe Y, Koshiyama M, Seki K, Nakagawa M, Ikuta E, Oowaki M, Sakamoto SI. Development and Themes of Diagnostic and Treatment Procedures for Secondary Leg Lymphedema in Patients with Gynecologic Cancers. Healthcare (Basel) 2019; 7:healthcare7030101. [PMID: 31461980 PMCID: PMC6787693 DOI: 10.3390/healthcare7030101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/23/2022] Open
Abstract
Patients with leg lymphedema sometimes suffer under constraint feeling leg heaviness and pain, requiring lifelong treatment and psychosocial support after surgeries or radiation therapies for gynecologic cancers. We herein review the current issues (a review of the relevant literature) associated with recently developed diagnostic procedures and treatments for secondary leg lymphedema, and discuss how to better manage leg lymphedema. Among the currently available diagnostic tools, indocyanine green lymphography (ICG-LG) can detect dermal lymph backflow in asymptomatic legs at stage 0. Therefore, ICG-LG is considered the most sensitive and useful tool. At symptomatic stage ≥1, ultrasonography, magnetic resonance imaging-lymphography/computed tomography-lymphography (MRI-LG/CT-LG) and lymphosintiography are also useful. For the treatment of lymphedema, complex decongestive physiotherapy (CDP) including manual lymphatic drainage (MLD), compression therapy, exercise and skin care, is generally performed. In recent years, CDP has often required effective multi-layer lymph edema bandaging (MLLB) or advanced pneumatic compression devices (APCDs). If CDP is not effective, microsurgical procedures can be performed. At stage 1–2, when lymphaticovenous anastomosis (LVA) is performed, lymphaticovenous side-to-side anastomosis (LVSEA) is principally recommended. At stage 2–3, vascularized lymph node transfer (VLNT) is useful. These ingenious procedures can help maintain the patient’s quality of life (QOL) but unfortunately cannot cure lymphedema. The most important concern is the prevention of secondary lymphedema, which is achieved through approaches such as skin care, weight control, gentle limb exercises, avoiding sun and heat, and elevation of the affected leg.
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Affiliation(s)
- Yumiko Watanabe
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Masafumi Koshiyama
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan.
| | - Keiko Seki
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Miwa Nakagawa
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Eri Ikuta
- School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Makiko Oowaki
- Department of Women's Health, Graduate School of Human Nursing, The University of Shiga Prefecture, Shiga 522-8533, Japan
| | - Shin-Ichi Sakamoto
- School of Engineering, Department of Electronic Systems Engineering, The University of Shiga Prefecture, Shiga 522-8533, Japan
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28
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Ciudad P, Sabbagh MD, Agko M, Huang TCT, Manrique OJ, L CR, Reynaga C, Delgado R, Maruccia M, Chen HC. Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review. Indian J Plast Surg 2019; 52:81-92. [PMID: 31456616 PMCID: PMC6664851 DOI: 10.1055/s-0039-1688537] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Tony C T Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Carmen Román L
- Department of Physical and Rehabilitation Medicine, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Cesar Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Ricardo Delgado
- Department of Plastic and Reconstructive Surgery, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Michele Maruccia
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Chilgar RM, Khade S, Chen HC, Ciudad P, Yeo MSW, Kiranantawat K, Maruccia M, Li K, Zhang YX, Nicoli F. Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures. Lymphat Res Biol 2019; 17:637-646. [PMID: 31038386 DOI: 10.1089/lrb.2018.0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.
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Affiliation(s)
- Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Sujit Khade
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Matthew Sze-Wei Yeo
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Department of Plastic and Reconstructive Surgery, Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, United Kingdom
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30
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Liu HL, Chung JCK. The Lymph Node Content of Supraclavicular Lymph Node Flap: A Histological Study on Fresh Human Specimens. Lymphat Res Biol 2019; 17:537-542. [PMID: 30694716 DOI: 10.1089/lrb.2018.0056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Vascularized lymph node transfer (VLNT) has become the established treatment for secondary lymphedema. The proposed mechanisms of VLNT include lymphangiogenesis and absorptive action of transplanted lymphatic tissue. Therefore, in theory, the lymph node content of lymph node flap is crucial to clinical response. The supraclavicular lymph node flap (SCLNF) has been described as one of the flap options for VLNT. However, its lymph node content has not been fully studied. The aim of this study is to find out the lymph node content of SCLNF with histological examination. Methods: Patients who required radical neck dissection or modified radical neck dissection due to cervical lymph node metastasis from head and neck cancer were included in this study. The SCLNF harvesting was performed as the first part of neck dissection. After flap harvesting, neck dissection was continued. The fresh SCLNF specimens were then sent for histological study. Results: Twelve SCLNFs were studied. The mean age of patients was 67.5 (range, 54-84) years. There were 10 males and 2 females. Seven flaps were harvested from the left side of neck, while five flaps were harvested from the right side of neck. The mean width, height, and thickness of SCLNF were 5.9 ± 0.6, 4.0 ± 0.5, and 1.8 ± 0.2 cm, respectively. The mean number of lymph nodes per flap was 8 ± 4.7 (range, 3-15). Conclusion: The lymph node content of SCLNF was confirmed. Its lymph node content is comparable to other lymph node flaps used in VLNT.
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Affiliation(s)
- Hin-Lun Liu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Joseph Chun-Kit Chung
- Department of Ear, Nose and Throat, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
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31
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Ciudad P, Agko M, Huang TCT, Manrique OJ, Chang WL, Nicoli F, Maruccia M, Lo Torto F, Chen HC. Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures. J Surg Oncol 2019; 119:430-438. [PMID: 30613978 DOI: 10.1002/jso.25356] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/16/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Burn Surgery; Arzobispo Loayza National Hospital; Lima Peru
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Section of Plastic Surgery; Medical College of Georgia, Augusta University; Augusta Georgia
| | - Tony C. T. Huang
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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32
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Ciudad P, Manrique OJ, Adabi K, Huang TCT, Agko M, Trignano E, Chang WL, Chen TW, Salgado CJ, Chen HC. Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema. J Surg Oncol 2019; 119:439-448. [DOI: 10.1002/jso.25360] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/19/2018] [Accepted: 12/16/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Burn Surgery; Arzobispo Loayza National Hospital; Lima Peru
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | | | - Mouchammed Agko
- Department of Plastic Surgery; Medical College of Georgia; Augusta University; Augusta Georgia
| | - Emilio Trignano
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Tsung-Wei Chen
- Department of Pathology; China Medical University; Taichung Taiwan
| | - Christopher J. Salgado
- Division of Plastic, Reconstructive and Aesthetic Surgery; University of Miami Miller School of Medicine; Miami Florida
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
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33
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Gould DJ, Mehrara BJ, Neligan P, Cheng MH, Patel KM. Lymph node transplantation for the treatment of lymphedema. J Surg Oncol 2018; 118:736-742. [PMID: 30129675 DOI: 10.1002/jso.25180] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/05/2022]
Abstract
Lymphedema is a complex disease process with deranged lymphatic transport, fluid accumulation and secondary lipedema and fibrosis. This is a challenging disease to treat with a surgical focus on debulking and physiologic strategies. One strategy is the use of vascularized lymph node transplant (VLNT) to improve physiologic lymph clearance. In this article, VLNT is discussed in detail, including mechanisms, combined strategies, and outcomes.
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Affiliation(s)
- Daniel J Gould
- Division of Plastic and Reconstructive Surgery, University of Southern California, California
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery, Service, Memorial Sloan-Kettering Cancer Center, New York
| | - Peter Neligan
- Department of Plastic Surgery, University of Washington Medical Center, Washington
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Taiwan
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, University of Southern California, California
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34
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Inatomi Y, Yoshida S, Kamizono K, Hanada M, Yasumatsu R, Kadota H. Successful treatment of severe facial lymphedema by lymphovenous anastomosis. Head Neck 2018; 40:E73-E76. [DOI: 10.1002/hed.25206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/17/2018] [Accepted: 03/20/2018] [Indexed: 11/07/2022] Open
Affiliation(s)
- Yusuke Inatomi
- Department of Plastic and Reconstructive Surgery; Kyushu University Hospital; Fukuoka Japan
| | - Sei Yoshida
- Department of Plastic and Reconstructive Surgery; Kyushu University Hospital; Fukuoka Japan
| | - Kenichi Kamizono
- Department of Plastic and Reconstructive Surgery; Kyushu University Hospital; Fukuoka Japan
| | - Masuo Hanada
- Department of Plastic and Reconstructive Surgery; Kyushu University Hospital; Fukuoka Japan
| | - Ryuji Yasumatsu
- Department of Otorhinolaryngology, Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Hideki Kadota
- Department of Plastic and Reconstructive Surgery; Kyushu University Hospital; Fukuoka Japan
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35
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Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018; 117:1420-1431. [PMID: 29572824 DOI: 10.1002/jso.25034] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Ketan Patel
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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36
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37
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38
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Ciudad P, Agko M, Perez Coca JJ, Manrique OJ, Chang WL, Nicoli F, Chen SH, Chen HC. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2017; 116:671-682. [PMID: 28695707 DOI: 10.1002/jso.24730] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/21/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
- Peru Plastic and Reconstructive Surgery Research Institute; Lima Peru
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - John Jaime Perez Coca
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang-Gung University; Linkou Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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39
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Recurrent Advanced Lower Extremity Lymphedema Following Initial Successful Vascularized Lymph Node Transfer: A Clinical and Histopathological Analysis. Arch Plast Surg 2017; 44:87-89. [PMID: 28194356 PMCID: PMC5300933 DOI: 10.5999/aps.2017.44.1.87] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 12/22/2016] [Accepted: 12/27/2016] [Indexed: 11/20/2022] Open
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40
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Sharkey AR, King SW, Ramsden AJ, Furniss D. Do surgical interventions for limb lymphoedema reduce cellulitis attack frequency? Microsurgery 2016; 37:348-353. [PMID: 27661464 DOI: 10.1002/micr.30115] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 08/25/2016] [Accepted: 09/02/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Recurrent cellulitis is a frequent and challenging complication of lymphoedema. British Lymphology Society cellulitis guidelines state that decongestive lymphatic therapy reduces the frequency of cellulitis attacks, but do not mention the effect of surgical interventions. This systematic review aims to assess whether surgical interventions for lymphoedema reduce the frequency of attacks of cellulitis. MATERIALS AND METHODS Embase, Medline, and the Cochrane database were searched for relevant articles from database inception to January 2016. Four hundred and thirty-six abstracts were retrieved. Studies were included which contained quantitative data on cellulitis incidence before and after a surgical intervention. Two independent reviewers applied selection criteria, selecting 27 papers for full text review. Two were unavailable in the UK from any source. RESULTS A variety of surgical techniques were utilized in the 25 papers included: lymphaticovenous anastomosis, superficial-to-deep lymphaticolymphatic anastomosis, lymph node transfer, Charles procedure, muscle flap transfer, Homan's procedure, and subcutaneous tissue excision below skin flaps. Five studies combined techniques. One study compared the intervention to a control group (physical therapy). Cellulitis incidence was decreased following surgical intervention in 24/25 studies included. Eight had quantifiable reductions in cellulitis over a set follow-up period; in the other 16 preoperative incidence was not precisely defined. CONCLUSION Surgery appears effective at reducing cellulitis incidence in lymphoedema. However, high quality evidence from randomized controlled trials is lacking. Future research should concentrate on comparison with control groups, for example compression alone versus compression with surgical intervention, in patients with lymphoedema and greater than two attacks of cellulitis per year.
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Affiliation(s)
- Amy R Sharkey
- Oxford University Medical School, John Radcliffe Hospital, Medical Sciences Divison, Oxford University, Oxford, Oxfordshire, OX3 9DU
| | - Samuel W King
- Oxford University Medical School, John Radcliffe Hospital, Medical Sciences Divison, Oxford University, Oxford, Oxfordshire, OX3 9DU
| | - Alexander J Ramsden
- Department of Plastic and Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford, OX3 7HE.,Oxford Lymphoedema Practice, Department of Plastic Surgery, The Manor Hospital, Beech Road, Oxford, OX3 7RP
| | - Dominic Furniss
- Department of Plastic and Reconstructive Surgery, Nuffield Orthopaedic Centre, Oxford, OX3 7HE.,Oxford Lymphoedema Practice, Department of Plastic Surgery, The Manor Hospital, Beech Road, Oxford, OX3 7RP.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, Oxford University, OX3 7HE
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41
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Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review. J Plast Reconstr Aesthet Surg 2016; 69:1234-47. [DOI: 10.1016/j.bjps.2016.06.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/18/2016] [Accepted: 06/22/2016] [Indexed: 11/17/2022]
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42
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Ciudad P, Manrique OJ, Date S, Sacak B, Chang WL, Kiranantawat K, Lim SY, Chen HC. A head-to-head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6-year single center experience. J Surg Oncol 2016; 115:37-42. [PMID: 27440739 DOI: 10.1002/jso.24349] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Seong Yoon Lim
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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43
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Scaglioni MF, Arvanitakis M, Chen YC, Giovanoli P, Chia-Shen Yang J, Chang EI. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery 2016; 38:222-229. [PMID: 27270748 DOI: 10.1002/micr.30079] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 04/28/2016] [Accepted: 05/13/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Lymphedema remains a challenging clinical problem. A new field of lymphatic surgery using micro and super microsurgery techniques is a rapidly advancing field aimed to treat recalcitrant cases. The objective of this study was to evaluate outcomes and complications of vascularized lymph node transfer (VLNT). Several early preliminary studies have reported promising outcomes, but they are limited by small numbers, short follow-up, and are inconsistent in addressing the origin and recipient site of the transferred lymph nodes as well as the donor site morbidity. METHODS A review of literature was conducted using PubMed-MEDLINE, EMBASE for key words vascularized lymph node transfer (also autologous, lymph node transplant). Only human studies were included. RESULTS A total 24 studies encompassing 271 vascularized lymph node transfers were included. The inguinal nodes were the most commonly used donor site followed by the lateral thoracic lymph nodes. The lateral thoracic lymph nodes were the least effective and had the highest complication rates (27.5%) compared to other lymph node donor sites (inguinal: 10.3% and supraclavicular: 5.6%). Upper extremity lymphedema responded better compared to lower extremity (74.2 vs. 53.2%), but there was no difference in placing the lymph nodes more proximally versus distally on the extremity (proximal: 76.9% vs. distal: 80.4%). CONCLUSION Vascularized lymph node transfer for lymphedema treatment is a promising operative technique showing beneficial results in early but also in advanced stage lymphedema. This physiologic surgical procedure should be included in a modern reconstructive concept for lymphedema treatment. © 2016 Wiley Periodicals, Inc. Microsurgery 38:222-229, 2018.
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Affiliation(s)
- Mario F Scaglioni
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Arvanitakis
- Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Yen-Chou Chen
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pietro Giovanoli
- Department of Plastic and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Johnson Chia-Shen Yang
- Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Edward I Chang
- Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX
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44
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Vives F, García-Perdomo HA, Ocampo-Flórez GM. Giant lymphedema of the penis and scrotum: a case report. AUTOPSY AND CASE REPORTS 2016; 6:57-61. [PMID: 27284543 PMCID: PMC4880436 DOI: 10.4322/acr.2016.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/13/2016] [Indexed: 11/23/2022] Open
Abstract
Lymphedema of the penis and scrotum is a rare entity characterized by enlargement of the skin and subcutaneous tissue of the genital region due to lymphatic drainage impairment. This clinical condition is more frequent in tropical countries due to a higher incidence of filariasis, which, in turn, is the main etiology. We describe the case of a 33-year-old man with large lymphedema of the scrotum and penis due to an acute and chronic inflammatory process, foreign body granuloma, and marked hyalinization. Four consecutive surgical interventions were necessary to remove the great part of the affected tissue, which enabled satisfactory results and improved the patient's quality of life.
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Affiliation(s)
- Franklin Vives
- Urology Oncologist - Surgical Oncologists from the Caribbean - Clinic of Sun, Barranquilla - Colombia
| | - Herney Andrés García-Perdomo
- Urology Department - Evaristo García University Hospital - University of Valle, Cali - Colombia.; Cochrane Group, Cali - Colombia
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45
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Cook KH, Park MC, Lee IJ, Lim SY, Jung YS. Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection. J Breast Cancer 2016; 19:92-5. [PMID: 27064862 PMCID: PMC4822114 DOI: 10.4048/jbc.2016.19.1.92] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 07/17/2015] [Indexed: 11/30/2022] Open
Abstract
Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.
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Affiliation(s)
- Kyung Hoon Cook
- Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Myong Chul Park
- Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Seong Yoon Lim
- Department of Plastic and Reconstructive Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yong Sik Jung
- Department of Surgery, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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46
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Visconti G, Brunelli C, Mulè A, Franceschini G, Chen HC, Masetti R, Salgarello M. Septum-based cervical lymph-node free flap in rat: a new model. J Surg Res 2016; 201:1-12. [DOI: 10.1016/j.jss.2015.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 08/09/2015] [Accepted: 09/22/2015] [Indexed: 11/28/2022]
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47
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Ciudad P, Date S, Orfaniotis G, Dower R, Nicoli F, Maruccia M, Lin SP, Chuang CY, Chuang TY, Wang GJ, Chen HC. Delayed grafting for banked skin graft in lymph node flap transfer. Int Wound J 2016; 14:125-129. [PMID: 26833759 DOI: 10.1111/iwj.12570] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 12/21/2015] [Indexed: 11/27/2022] Open
Abstract
Over the last decade, lymph node flap (LNF) transfer has turned out to be an effective method in the management of lymphoedema of extremities. Most of the time, the pockets created for LNF cannot be closed primarily and need to be resurfaced with split thickness skin grafts. Partial graft loss was frequently noted in these cases. The need to prevent graft loss on these iatrogenic wounds made us explore the possibility of attempting delayed skin grafting. We have herein reported our experience with delayed grafting with autologous banked split skin grafts in cases of LNF transfer for lymphoedema of the extremities. Ten patients with International Society of Lymphology stage II-III lymphoedema of upper or lower extremity were included in this study over an 8-month period. All patients were thoroughly evaluated and subjected to lymph node flap transfer. The split skin graft was harvested and banked at the donor site, avoiding immediate resurfacing over the flap. The same was carried out in an aseptic manner as a bedside procedure after confirming flap viability and allowing flap swelling to subside. Patients were followed up to evaluate long-term outcomes. Flap survival was 100%. Successful delayed skin grafting was done between the 4th and 6th post-operative day as a bedside procedure under local anaesthesia. The split thickness skin grafts (STSG) takes more than 97%. One patient needed additional medications during the bedside procedure. All patients had minimal post-operative pain and skin graft requirement. The patients were also reported to be satisfied with the final aesthetic results. There were no complications related to either the skin grafts or donor sites during the entire period of follow-up. Delayed split skin grafting is a reliable method of resurfacing lymph node flaps and has been shown to reduce the possibility of flap complications as well as the operative time and costs.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,PhD Program in Tissue Engineering and Regenerative Medicine, National Chung Hsing University, Taichung, Taiwan.,Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Rory Dower
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shu-Ping Lin
- Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Chu-Yi Chuang
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tsan-Yu Chuang
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Gou-Jen Wang
- PhD Program in Tissue Engineering and Regenerative Medicine, National Chung Hsing University, Taichung, Taiwan.,Graduate Institute of Biomedical Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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48
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Abstract
BACKGROUND Lymphedema can be classified as either primary or secondary. In the present study, the authors investigated the efficacy of lymphaticovenous anastomosis for correcting primary lower limb lymphedema and to determine its indications and contraindications. METHODS The authors retrospectively examined patients with primary lower limb lymphedema who underwent lymphaticovenous anastomosis between April of 2009 and September of 2013. Anastomosis efficacy was evaluated using lower limb circumference measurements at five anatomical locations. Lymphedema staging was determined using modified leg dermal backflow stage. The authors added two categories to the standard leg dermal backflow staging system: no backflow and distal backflow. Lymphaticovenous anastomosis was performed under local anesthesia, except in pediatric cases. RESULTS The authors evaluated 62 patients (79 lower limbs). Lower limb circumference increased after lymphaticovenous anastomosis in patients with an onset age of 1 year or later and before age 11 years, but it significantly decreased in patients with an onset age older than 11 years. The presence of lymphedema for a longer period did not negatively impact lymphaticovenous anastomosis efficacy. In particular, lymphaticovenous anastomosis was effective in the leg dermal backflow stage 2 and no backflow group. CONCLUSIONS For patients developing lymphedema before 11 years of age, the indications should be considered carefully. However, lymphaticovenous anastomosis was effective in patients developing lymphedema after the age of 11 years. Regardless, due to its low level of invasiveness, lymphaticovenous anastomosis may be considered for patients who are refractory to conservative treatment, even if they have early-onset lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Lymph node content of supraclavicular and thoracodorsal-based axillary flaps for vascularized lymph node transfer. J Vasc Surg Venous Lymphat Disord 2016; 4:80-7. [DOI: 10.1016/j.jvsv.2015.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 06/29/2015] [Indexed: 11/21/2022]
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Nicoli F, Orfaniotis G, Lazzeri D, Lim SY, Kiranantawat K, Chen PY, Ciudad P, Chilgar RM, Sapountzis S, Sacak B, Chen HC. The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema. Microsurgery 2015; 36:689-694. [PMID: 26466971 DOI: 10.1002/micr.22515] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 07/28/2015] [Accepted: 09/25/2015] [Indexed: 11/11/2022]
Abstract
Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.
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Affiliation(s)
- Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, UK
| | - Davide Lazzeri
- Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy
| | - Seong Yoon Lim
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pei-Yu Chen
- Department of Pathology, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Stamatis Sapountzis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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