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Demiri E, Dionyssiou D, Kyriazidis I, Drougou A, Tsimponis A. Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach. JPRAS Open 2024; 40:1-18. [PMID: 38389651 PMCID: PMC10879689 DOI: 10.1016/j.jpra.2024.01.010] [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: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/24/2024] Open
Abstract
The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.
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Affiliation(s)
- Efterpi Demiri
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
- Interbalkan Medical Center, Thessaloniki Greece
| | - Dimitrios Dionyssiou
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
- Interbalkan Medical Center, Thessaloniki Greece
| | - Ioannis Kyriazidis
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
| | - Avra Drougou
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
| | - Antonios Tsimponis
- Department of Plastic Surgery, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki Greece
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Yoo H, Hong KY, Min S, Lee HS, Park DJ, Kim YS, Kong SH, Chang H. Distribution of Perigastric Station 4d Lymph Nodes in Vascularized Gastroepiploic Lymph Node Transfer: An Anatomic Study and Case Series. Ann Surg Oncol 2024; 31:3694-3704. [PMID: 38530528 DOI: 10.1245/s10434-024-15113-2] [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: 12/27/2023] [Accepted: 02/12/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Vascularized gastroepiploic lymph node transfer (VGLNT) is a well-accepted surgical treatment for restoring physiological function in chronic lymphedema. However, the inclusion of substantial lymph nodes (LNs) in the flap remains uncertain. This study aimed to identify the anatomical basis for reliable flap harvest for VGLNT. PATIENTS AND METHODS The anatomy of perigastric station 4d LNs was studied in healthy cadavers (n = 15) and patients with early gastric cancer (EGC) (n = 27). The omentum was divided into three segments: proximal, middle, and distal from the origin of the right gastroepiploic vessels. The flap dimension, number, location, size of LNs, and caliber of the vessels were reviewed. Eight patients underwent VGLNT for upper/lower limb lymphedema. RESULTS The mean numbers of LNs in the proximal, middle, and distal segment were 2.5, 1.4, 0.5 in the cadavers, and 4.9, 2.7, 0.7 in the gastrectomy specimens, respectively. The proximal third included a significantly greater number of LNs than the distal third in the cadaveric (p = 0.024) and ECG (p = 0.016) specimens. A total of 95% of the LNs were located within proximal two-thirds of the flap from the vessel origin both in the cadavers (21.0 × 5.0 cm) and in the gastrectomy specimens (20 × 3.5 cm). In VGLNT, the transferred flap was 25.5 ± 6.9 × 4.1 + 0.7 cm in dimension, containing a mean number of 6.5 ± 1.9 LNs. At postoperative 6 months, the volumetric difference was significantly reduced by 22.8 ± 9.2% (p < 0.001). CONCLUSIONS This study provides a distinct distribution pattern of station 4d LNs. Inclusion of the proximal two-thirds of the flap, which carries majority of the LNs, is recommended for VGLNT.
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Affiliation(s)
- Hyokyung Yoo
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ki Yong Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sally Min
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hye Seung Lee
- Department of Pathology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Do-Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yi-Suk Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Garg P, Borle F. Vascularized Lymph Node Transfer Surgery for Successful Resolution of Long-Standing Lower Limb Lymphedema With Charles Excision: A Case Report. Cureus 2024; 16:e59000. [PMID: 38800178 PMCID: PMC11127703 DOI: 10.7759/cureus.59000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/21/2024] [Indexed: 05/29/2024] Open
Abstract
Lymphedema, a chronic condition characterized by abnormal swelling resulting from impaired lymphatic drainage, poses significant challenges in clinical management, especially when conventional therapies prove ineffective. This case report elucidates the successful resolution of long-standing lower limb lymphedema in a 35-year-old male through innovative surgical interventions. Despite enduring symptoms for 15 years and undergoing various treatments without improvement, the patient achieved remarkable relief following vascularized lymph node transfer surgery combined with Charles excision. This multidisciplinary approach aimed to restore lymphatic function and alleviate tissue bulk, addressing the condition's functional and cosmetic aspects. Preoperative evaluations, including imaging studies confirming grade IV lymphedema, guided surgical planning and contributed to the successful outcome. Postoperatively, despite wound dehiscence, prompt management facilitated satisfactory wound healing, underscoring the importance of meticulous postoperative care. This case underscores the significance of surgical intervention in managing refractory lymphedema and emphasizes the need for tailored treatment strategies to optimize patient outcomes. Further research and clinical experience are warranted to refine surgical techniques and identify optimal patient selection criteria, advancing the management of this challenging condition.
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Affiliation(s)
- Pankhuri Garg
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Firoz Borle
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Alarcón PZ, Torrano L, Ibarra A, Garrido MF, Playa GP, Masia J. Prophylactic lymphedema surgery in lower limb soft tissue sarcomas: A clinical paradigm in a promising field. J Plast Reconstr Aesthet Surg 2024; 88:524-534. [PMID: 38113721 DOI: 10.1016/j.bjps.2023.11.036] [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: 11/27/2022] [Revised: 11/19/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
INTRODUCTION Oncological treatments, such as radiotherapy and surgery, are high-risk factors for the development of secondary lymphedema in the upper and lower limbs, as well as the genitalia. Prophylactic lymphedema surgery (PLS) has previously demonstrated promising results in reducing secondary lymphedema in breast cancer and urogenital cancer patients. We conducted a study to adapt this principle for patients with lower-extremity sarcomas. MATERIAL AND METHODS Inclusion criteria included patients with tumors on the medial aspect of the thigh and leg and tumor size larger than 5 cm. Group A (19 patients) comprised a prospective cohort (2020-2023) in which a PLS protocol was executed. Lymphaticovenous anastomosis (LVA) was performed when lymphatic channels were interrupted due to tumor resection, intraoperatively verified by indocyanine green. Lymph node transfer was employed exclusively in cases involving preoperative radiotherapy and inguinal lymph node resection. Measurements were collected both preoperatively and at 1, 3, 6, and 12 months postoperatively. Group B (26 patients) constituted a retrospective cohort (2017-2020) without PLS reconstruction, where the prevalence of lymphedema was determined. RESULTS In total, we enrolled 45 patients with soft tissue sarcomas located on the inner aspect of the thigh and leg (26 in the control group vs. 19 in the prophylactic group). In the control group, lymphedema was observed in 10 out of 27 patients (37.04%). In the prophylactic group, two patients exhibited signs of lower-extremity lymphedema (2/19, 10.52%) with a median follow-up of 14.15 months (6 months-33months), demonstrating statistically significant differences between the two groups (p = 0.02931). CONCLUSIONS PLS for lower limb soft tissue sarcomas shows promising results, although it is premature to reach solid conclusions. Multicentre studies, standardization of criteria, larger sample sizes and longer-term follow-up are imperative for further validation.
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Affiliation(s)
- Paúl Zamora Alarcón
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Laura Torrano
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - Andree Ibarra
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Manuel Fernández Garrido
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Gemma Pons Playa
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Jaume Masia
- Department of Plastic and Reconstructive Surgery, Hospital de la Sant Creu i Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
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Zhang X, Beeraka NM, Sinelnikov MY, Glazachev OS, Ternovoy KS, Lu P, Isaeva A, Cao Y, Zhang J, Nezhad AB, Plotnikova M, Chen K. Breast Cancer-related Lymphedema: Recent Updates on Clinical Efficacy of Therapies and Bioengineering Approaches for a Personalized Therapy. Curr Pharm Des 2024; 30:63-70. [PMID: 38141193 DOI: 10.2174/0113816128269545231218075040] [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: 09/22/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Post-mastectomy lymphedema is a chronic progressive disease characterized by a significant reduction in quality of life and a range of complications. AIM To this date, no single treatment method provides pathological correction of the mechanisms associated with tissue reorganization observed in later-stage breast cancer-related lymphedema (BCRL). METHODS To define a personalized approach to the management of patients with iatrogenic lymphedema, we performed a systematic review of literature without a comprehensive meta-analysis to outline existing molecular- genetic patterns, overview current treatment methods and their efficacy, and highlight the specific tissue-associated changes in BCRL conditions and other bio-engineering approaches to develop personalized therapy. RESULTS Our results show that several tissue-specific and pathological molecular markers may be found, yet current research does not aim to define them. CONCLUSION As such, currently, a strong foundation for further research into molecular-genetic changes in lymphedema tissue exists, and further research should focus on finding specific targets for personalized treatment through bio-engineering approaches.
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Affiliation(s)
- Xinliang Zhang
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Narasimha M Beeraka
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
- Department of Biotechnology, Raghavendra Institute of Pharmaceutical Education and Research (RIPER), Anantapuramu, Chiyyedu, Andhra Pradesh 515721, India
- Herman B. Wells Center for Pediatric Research, Department of Pediatrics, Indiana University School of Medicine, 1044 W. Walnut Street, R4-168, Indianapolis, IN 46202, Indiana, USA
| | - Mikhail Y Sinelnikov
- Department of Cancer Research, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
- Research Institute of Human Morphology, Moscow, Russian Federation
| | - Oleg S Glazachev
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Konstantin S Ternovoy
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Pengwei Lu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshedong Street, Zhengzhou 450052, China
| | - Aida Isaeva
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Yu Cao
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Jin Zhang
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Arshia Bakhtiari Nezhad
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Maria Plotnikova
- Department of Human Anatomy, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), 8/2 Trubetskaya Street, Moscow 119991, Russia
| | - Kuo Chen
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, 1 Jianshedong Street, Zhengzhou 450052, China
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Bernas M, Al-Ghadban S, Thiadens SRJ, Ashforth K, Lin WC, Safa B, Buntic R, Paukshto M, Rovnaya A, McNeely ML. Etiology and treatment of cancer-related secondary lymphedema. Clin Exp Metastasis 2023:10.1007/s10585-023-10232-8. [PMID: 37777696 DOI: 10.1007/s10585-023-10232-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/28/2023] [Indexed: 10/02/2023]
Abstract
Lymphedema and specifically cancer-related lymphedema is not the main focus for both patients and physicians dealing with cancer. Its etiology is an unfortunate complication of cancer treatment. Although lymphedema treatments have gained an appreciable consensus, many practitioners have developed and prefer their own specific protocols and this is especially true for conventional (manual) versus surgical treatments. This collection of presentations explores the incidence and genetics of cancer-related lymphedema, early detection and monitoring techniques, both conventional and operative treatment options, and the importance and role of exercise for patients with cancer-related lymphedema. These assembled presentations provide valuable insights into the challenges and opportunities presented by cancer-related lymphedema including the latest research, treatments, and exercises available to improve patient outcomes and quality of life.
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Affiliation(s)
- Michael Bernas
- Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, TX, USA.
| | - Sara Al-Ghadban
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | | | - Karen Ashforth
- St. Joseph's Medical Center, University of the Pacific, Stockton, CA, USA
| | - Walter C Lin
- Buncke Clinic, San Francisco, CA, USA
- Department of Surgery, Saint Francis Memorial Hospital, San Francisco, CA, USA
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Lee JW, Lee TY, Moon KC, You HJ, Kim DW. Lymphatic complex transfer as combined lymph vessel and node transfer for advanced stage upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:824-831.e3. [PMID: 36906107 DOI: 10.1016/j.jvsv.2023.02.003] [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: 11/02/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE Lymphedema, especially in the advanced stage, is a growing challenge in extremity reconstruction, with few applicable surgical methods. Despite its importance, no consensus has been reached regarding a single surgical method yet. Herein, the authors introduce a novel concept of lymphatic reconstruction yielding promising results. METHODS We included 37 patients with advanced-stage upper extremity lymphedema who underwent lymphatic complex transfers, consisting of both lymph vessel and node transfers, from 2015 to 2020. We compared the preoperative and postoperative (last visit) mean circumferences and volume ratios between the affected and unaffected limbs. Changes in the Lymphedema Life Impact Scale scores and complications were also investigated. RESULTS The circumference ratio (affected to unaffected limbs) improved at all measuring points (P < .05), while the volume ratio showed a decrease from 1.54 to 1.39 (P < .001). The mean Lymphedema Life Impact Scale decreased from 48.1 ± 15.2 to 33.4 ± 13.8 (P < .05). No donor site morbidities, including iatrogenic lymphedema or any other major complications, were observed. CONCLUSIONS A new technique for lymphatic reconstruction, lymphatic complex transfer, may be useful in cases of advanced stage lymphedema because of its effectiveness and the low possibility of donor site lymphedema.
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Affiliation(s)
- Jun Won Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Tae-Yul Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyung-Chul Moon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hi-Jin You
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Deok-Woo Kim
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea.
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Bianchi LMG, Irmici G, Cè M, D'Ascoli E, Della Pepa G, Di Vita F, Casati O, Soresina M, Menozzi A, Khenkina N, Cellina M. Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What's New? Curr Oncol 2023; 30:4512-4526. [PMID: 37232799 DOI: 10.3390/curroncol30050341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/24/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.
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Affiliation(s)
| | - Giovanni Irmici
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Maurizio Cè
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Elisa D'Ascoli
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Gianmarco Della Pepa
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Filippo Di Vita
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Omar Casati
- Postgraduation School in Plastic Surgery, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
| | - Natallia Khenkina
- Postgraduation School in Radiodiagnostics, University of Milan, 20122 Milan, Italy
| | - Michaela Cellina
- Radiology Department, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, 20121 Milan, Italy
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Roka-Palkovits J, Freystätter C, Tinhofer IE, Keck M, Steinbacher J, Meng S, Weninger WJ, Cheng MH, Tzou CHJ. Retroauricular lymph node flap: An anatomic and surgical feasibility study. J Surg Oncol 2023; 127:1103-1108. [PMID: 36912899 DOI: 10.1002/jso.27234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/26/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.
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Affiliation(s)
- Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Christian Freystätter
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Austria
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Maike Keck
- Department of Plastic and Reconstructive Surgery, Agaplesion Diakonieklinikum Hamburg, Hamburg, Germany.,Department of Plastic and Reconstructive Surgery, University of Luebeck, Luebeck, Germany
| | - Johannes Steinbacher
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria
| | - Stefan Meng
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
| | - Wolfgang J Weninger
- Division of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chieh-Han J Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior (Krankenhaus Goettlicher Heiland), Vienna, Austria.,Faculty of Medicine, Sigmund Freud University, Vienna, Austria.,Lymphedema Center, TZOU MEDICAL., Vienna, Austria
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10
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von Fritschen U, Seidenstücker K, Sigalove S. Current trends in postmastectomy breast reconstruction. Curr Opin Obstet Gynecol 2023; 35:73-79. [PMID: 36165007 DOI: 10.1097/gco.0000000000000828] [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: 02/04/2023]
Abstract
PURPOSE OF REVIEW Breast reconstruction is established as integral part of the treatment. New materials, indications and surgical techniques are subject to rapid modification to further improve safety, quality and longevity. RECENT FINDINGS Skin-sparing-mastectomy is accepted as an appropriate alternative in risk-reducing and many breast cancer patients, further reducing conventional mastectomy patterns.Radiation in combination with reconstruction is still challenging with no clear advances reducing skin-toxicity.Autologous reconstructions, not only in radiation settings, are turning to a first line approach. A trend driven by improved techniques to minimize morbidity and flap-variations.Breast implant surfaces associated with a high risk of Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are now withdrawn. The residual risk for the remaining implant styles is not known, but can be expected considerably lower than estimations published presently.In order to reduce local complications, supplemental material often in combination with prepectoral implant placement is advertised. The present evidence on long-term outcome is limited.Super-microsurgery treating lymphedema is evolving rapidly. Refinements of various techniques and their differential indication are under evaluation to standardize the procedures. SUMMARY Breast reconstruction evolved to a complex, specialized field with a multitude of options. A multidisciplinary team is required to fully utilize todays potential and offer optimal individual treatments.
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Affiliation(s)
- Uwe von Fritschen
- Department of Plastic and Aesthetic Surgery, Hand Surgery, HELIOS Hospital Emil von Behring, Berlin
| | - Katrin Seidenstücker
- Sana Kliniken Düsseldorf, Department of Plastic Surgery
- University of Düsseldorf (UKD) - Department of Gynecology, Düsseldorf, Germany
| | - Steven Sigalove
- Scottsdale Center for Plastic Surgery, Paradise Valley, Arizona, USA
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Nakatsuka K, Fuse Y, Karakawa R, Yano T, Yoshimatsu H. Comparing seroma formation rate after harvest of the deep inferior epigastric artery perforator flap and the superficial abdominal perforator flaps in autologous breast reconstruction: A propensity-matched analysis. Microsurgery 2023; 43:39-43. [PMID: 36177863 DOI: 10.1002/micr.30969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 08/28/2022] [Accepted: 09/02/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Donor site seroma formation and prolonged drainage duration are commonly seen after harvest of perforator-based abdominal flaps. The lymphatic network including the lymphatic vessels and the lymph nodes can be traumatized during harvest of a perforator-based abdominal flap, eventually causing seroma formation. The aim of this study was to compare postoperative seroma occurrence rates between the deep system group including the deep inferior epigastric artery perforator (DIEP) flap and the superficial system group comprised of the superficial inferior epigastric artery (SIEA) flap, the superficial circumflex iliac artery perforator (SCIP) flap, and the SIEA-SCIP combined flap. PATIENTS AND METHODS A retrospective analysis of all patients who underwent unilateral breast reconstruction using perforator-based abdominal flaps from June 2020 to May 2021 was performed. The patients were divided into the deep system group and the superficial system group. Propensity score matching was used to compare in the two groups the mean duration of drainage in the donor site and the occurrence of postoperative aspiration. Covariates included sex, age, body mass index, history of smoking, past history of diabetes mellitus. One hundred and fifteen patients (the deep system group, n = 100 and the superficial system group, n = 15) met inclusion criteria for a 1:1 match performed on 14 deep system group patients using propensity scores, with 14 superficial system group patients having similar characteristics. RESULTS The mean duration of drainage in the donor site was shorter in the deep system group (6.6 ± 1.9 days) than in the superficial system group (9.3 ± 2.3 days, p < .01). The occurrence rate of postoperative aspiration was lower in the deep system group (0%) than in the superficial system group (50%, p < .01). CONCLUSIONS Although superficial abdominal perforator flaps are considered to be less invasive than the DIEP flap, they are associated with prolonged donor site drainage and more frequent occurrence rate of postoperative aspiration.
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Affiliation(s)
- Kengo Nakatsuka
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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12
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Combining reconstructive and ablative surgical treatment of chronic breast cancer-related lymphedema (BCRL): safe and effective. Breast Cancer Res Treat 2023; 197:83-92. [PMID: 36287309 PMCID: PMC9823021 DOI: 10.1007/s10549-022-06778-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/13/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE We investigated whether a one-stage combination of vascularized lymph node transfer (VLNT) with water jet-assisted liposuction (WAL) can be safely performed and results in improved patient outcomes such as a greater reduction in arm volume when treating chronic breast cancer-related lymphedema (BCRL). METHODS In this retrospective cohort study, we included all patients from our encrypted lymphedema database treated for chronic BCRL with VLNT or VLNT + WAL who had a minimum follow-up of two years. We analyzed patient-specific variables including arm circumferences as well as patient-reported outcomes before and after surgery as well as surgery time, surgery-related complications and patient satisfaction. RESULTS Only the mean preoperative differences of the circumferences between the lymphedematous and the unaffected arm in individual patients showed a statistically significant difference between treatment groups (p < 0.05). Indeed, patients treated with VLNT + WAL had consistently larger differences in individual sets of arms and therefore more pronounced chronic BCRL. The mean surgery time was significantly longer in the VLNT + WAL group (p < 0.05). Complications were seldom and similar in both groups. Using a numeric rating scale, the level of patient satisfaction following treatment did not differ significantly between groups (p = 0.323). CONCLUSIONS Our findings suggest that a one-stage combination of VLNT with WAL does not result in more complications even though it also entails a longer surgery time. This is acceptable as secondary interventions resulting in overall longer surgery times and higher costs can be avoided. A one-stage combination might be especially favourable for patients suffering from more severe chronic BCRL.
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13
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Chu CK, Hanasono MM, Chang EI. Treatment of multiple limb lymphedema with combined supermicrosurgical techniques. Microsurgery 2023; 43:13-19. [PMID: 35244958 DOI: 10.1002/micr.30878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 01/01/2022] [Accepted: 02/24/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Lymphedema surgery including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are effective treatments for lymphedema; however, treating multiple limbs in a single operation using both approaches has not been described. We hypothesize multiple limb lymphedema can be treated effectively in one operation. PATIENT AND METHODS Retrospective review of seven patients undergoing extreme lymphedema surgery (mean age: 53.2 years; range: 33-66 years) with an average BMI of 34.8 kg/m2 (range: 17.6-53.6 kg/m2 ). Two patients developed bilateral upper extremity (UE) lymphedema secondary to breast cancer treatment, three had bilateral lower extremity (LE) lymphedema, and two suffered from lymphedema of all four extremities due to breast cancer treatment. RESULTS One patient with bilateral UE lymphedema was treated with bilateral inguinal node transfers with LVA and the other with combined bilateral DIEP flaps and inguinal node transfers with LVA. Three patients had bilateral LE lymphedema: two were treated with split omental/gastroepiploic nodes, and one underwent simultaneous supraclavicular and submental node transfers. LVAs were performed in one leg in each patient. Two patients with four-limb lymphedema underwent bilateral inguinal node transfers with DIEP flaps and bilateral LE LVA. In total, there were eight UE and 10 LE treated. Average follow-up was 15.8 months (range: 12.6-28.4 months), all patients reported subjective improvement in symptoms, were able to decrease use of compression garments and pumps, and no patients developed cellulitis. CONCLUSION Patients suffering from lymphedema of multiple extremities can be treated safely and effectively combining both LVA and VLNT in a single operation.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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14
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Yamamoto T, Miyazaki T, Sakai H, Tsukuura R, Yamamoto N. Dermal-adipose lymphatic flap venous wrapping: A novel lymphaticovenous shunt method for progression of upper extremity lymphedema with severe lymphosclerosis. J Vasc Surg Venous Lymphat Disord 2022; 11:619-625.e2. [PMID: 36580998 DOI: 10.1016/j.jvsv.2022.10.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Upper extremity lymphedema (UEL) causes a significant deterioration in the quality of life of breast cancer survivors. Lymphaticovenous shunt creation will address the pathophysiology of obstructive UEL; however, its efficacy has been limited for those with UEL progression due to lymphosclerosis. In the present study, we evaluated the feasibility of a new lymphaticovenous shunt method for progression of UEL. METHODS A total of 37 patients who had undergone dermal-adipose lymphatic flap venous wrapping (DALF-VW) for the treatment of UEL progression refractory to previous lymphaticovenular anastomosis were included. A DALF was created where indocyanine green lymphography had shown dermal backflow and was wrapped with a reflux-free recipient vein. The patients' medical records were reviewed to obtain the clinical and intraoperative findings. The patient and vessel characteristics and postoperative results were evaluated. RESULTS A total of 37 patients with unilateral UEL were included. All DALF-VW procedures were performed under local infiltration anesthesia, with 98 shunts created in 37 limbs (2.6 shunts per limb). The diameter of the vein used for DALF-VW ranged from 1.7 to 3.3 mm (average, 2.39 mm). The operative time ranged from 25 to 139 minutes (average, 47.8 minutes). The differences in the lymphedema quality of life score (45.6 ± 21.1 vs 32.5 ± 21.1; P = .009), UEL index (131.4 ± 18.2 vs 123.1 ± 16.4; P = .042), and frequency of cellulitis (0.8 ± 1.3 vs 0.2 ± 0.5 times annually; P = .010) before and after DALF-VW were statistically significant. CONCLUSIONS DALF-VW was effective for UEL progression that was refractory to previous lymphaticovenular anastomosis surgery. DALF-VW could be a useful option for UEL progression with severe lymphosclerosis.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan; Department of Plastic Surgery, Noda Hospital, Chiba, Japan.
| | - Toko Miyazaki
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hayahito Sakai
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Reiko Tsukuura
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan; Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
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15
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McEvoy MP, Gomberawalla A, Smith M, Boccardo FM, Holmes D, Djohan R, Thiruchelvam P, Klimberg S, Dietz J, Feldman S. The prevention and treatment of breast cancer- related lymphedema: A review. Front Oncol 2022; 12:1062472. [PMID: 36561522 PMCID: PMC9763870 DOI: 10.3389/fonc.2022.1062472] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed. Methods The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included. Results The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations. Conclusions Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.
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Affiliation(s)
- Maureen P. McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States,*Correspondence: Maureen P. McEvoy,
| | - Ameer Gomberawalla
- Department of Surgery, Advocate Medical Group, Oak Lawn, IL, United States
| | - Mark Smith
- Department of Plastic Surgery, Northwell Health System, New Hyde Park, NY, United States
| | | | - Dennis Holmes
- Department of Surgery, Los Angeles Center for Women’s Health, Los Angeles, CA, United States
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Paul Thiruchelvam
- Department of Breast Surgery, Imperial College, London, United Kingdom
| | - Suzanne Klimberg
- Department of Surgery, University of Texas Medical Branch(UTMB) Cancer Center, Galveston, TX, United States
| | - Jill Dietz
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
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16
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Lee GK, Perrault DP, Bouz A, Pourmoussa AJ, Yu R, Kim SJ, Gardner D, Johnson M, Park SY, Park EK, Seong YJN, Lee S, Jung E, Choi D, Hong YK, Wong AK. Prolymphangiogenic Effects of 9- cis Retinoic Acid Are Enhanced at Sites of Lymphatic Injury and Dependent on Treatment Duration in Experimental Postsurgical Lymphedema. Lymphat Res Biol 2022; 20:640-650. [PMID: 35584281 PMCID: PMC9810351 DOI: 10.1089/lrb.2021.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background: Patients undergoing surgical treatment for solid tumors are at risk for development of secondary lymphedema due to intraoperative lymphatic vessel injury. The damaged lymphatic vessels fail to adequately regenerate and lymphatic obstruction leads to fluid and protein accumulation in the interstitial space and chronic lymphedema develops as a result. There are currently no effective pharmacological agents that reduce the risk of developing lymphedema or treat pre-existing lymphedema, and management is largely palliative. The present study investigated the efficacy of various 9-cis retinoic acid (9-cis RA) dosing strategies in reducing postsurgical lymphedema by utilizing a well-established mouse tail lymphedema model. Methods and Results: Short-duration treatment with 9-cis RA did not demonstrate a significant reduction in postoperative tail volume, nor an improvement in lymphatic clearance. However, long-term treatment with 9-cis RA resulted in decreased overall tail volume, dermal thickness, and epidermal thickness, with an associated increase in functional lymphatic clearance and lymphatic vessel density, assessed by LYVE-1 immunostaining, compared with control. These effects were seen at the site of lymphatic injury, with no significant changes observed in uninjured sites such as ear skin and the diaphragm. Conclusions: Given the reported results indicating that 9-cis RA is a potent promoter of lymphangiogenesis and improved lymphatic clearance at sites of lymphatic injury, investigation of postoperative 9-cis RA administration to patients at high risk of developing lymphedema may demonstrate positive efficacy and reduced rates of postsurgical lymphedema.
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Affiliation(s)
- Gene K. Lee
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - David P. Perrault
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Antoun Bouz
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Austin J. Pourmoussa
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Roy Yu
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Soo Jung Kim
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
| | - Daniel Gardner
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Maxwell Johnson
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Sun Young Park
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Eun Kyung Park
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Young Jin N. Seong
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Sunju Lee
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Eunson Jung
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
| | - Dongwon Choi
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Young-Kwon Hong
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Alex K. Wong
- Division of Plastic and Reconstructive Surgery and Keck School of Medicine of USC, Los Angeles, California, USA
- Department of Surgery, Keck School of Medicine of USC, Los Angeles, California, USA
- Division of Plastic Surgery, City of Hope National Medical Center, Duarte, California, USA
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17
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Lin WC, Safa B, Buntic RF. Approach to Lymphedema Management. Semin Plast Surg 2022; 36:260-273. [PMID: 36561430 PMCID: PMC9762993 DOI: 10.1055/s-0042-1758691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.
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Affiliation(s)
- Walter C. Lin
- Department of Surgery, The Buncke Clinic, San Francisco, California
| | - Bauback Safa
- Department of Surgery, The Buncke Clinic, San Francisco, California
| | - Rudolf F. Buntic
- Department of Surgery, The Buncke Clinic, San Francisco, California
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18
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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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19
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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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20
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Hirche C. [Autologous Breast Reconstruction in Conjuction with Lymphatic Microsurgery in Breast Cancer-Related Lymphedema]. HANDCHIR MIKROCHIR P 2022; 54:326-338. [PMID: 35944536 DOI: 10.1055/a-1868-5527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Breast cancer-related lymphedema of the upper extremity is the most significant non-oncological complication of tumour therapy, leading to functional impairment and impacting patients' quality of life. Autologous breast reconstruction per se effectively reduces incidence and stage of lymphedema after breast cancer treatment by surgical angiogenesis. In addition, modern surgical techniques for treating lymphedema are effective in reducing limb volume, circumference and functional impairment, and improving patients' quality of life, body image, integrity and local immunocompetence. Reconstructive surgery, including lymphovenous anastomoses (LVA) and vascularised lymph node transfer (VLNT), have been shown to rearrange or restore lymphatic flow and prevent stage progression. For patients with breast cancer-related lymphedema after mastectomy, autologous breast reconstruction in conjunction with lymphatic microsurgery using VLNT, LVA or a combination of these procedures offers the option of holistic and single-stage restoration in modern senology. Extensive scar release in the axilla is a crucial component of the surgical technique, aiming to prepare the recipient bed for the VLN transplant and to allow for the functional recruitment of remaining lymph vessels of the upper extremity. This article presents the indications, preoperative diagnostic evaluation, surgical techniques and precautions, complications and results of combined lymphatic and breast restoration.
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Affiliation(s)
- Christoph Hirche
- Abteilung für Plastische, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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21
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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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22
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Ciudad P, Escandón JM, Manrique OJ, Gutierrez-Arana J, Mayer HF. Lymphedema prevention and immediate breast reconstruction with simultaneous gastroepiploic vascularized lymph node transfer and deep inferior epigastric perforator flap: A case report. Microsurgery 2022; 42:617-621. [PMID: 35821630 DOI: 10.1002/micr.30939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/25/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
Breast cancer-related lymphedema following axillary lymph node dissection (ALND) has been documented in 6%-55% of patients, mostly occurring within the next 3 years after radiation or surgery. We present a case of a 53-year-old patient with hormone positive, stage IB, left breast invasive ductal carcinoma treated with immediate lymphatic and microvascular breast reconstruction (MBR) using vascularized lymph node transfer (VLNT) for lymphedema prevention. A deep inferior epigastric perforator (DIEP) flap (18.3 × 11.2-cm) and simultaneous prophylactic gastroepiploic-VLNT (7 × 3-cm), orthotopically inset in the axilla, were used for reconstruction following mastectomy and radical ALND. The procedure was uneventful. The patient did not display increased postoperative arm circumferences. ICG lymphography did not show any changes at 2- and 3-years after surgery. Preventive lymphatic reconstruction with GE-VLNT and immediate MBR using the DIEP flap offers a new possibility for the primary prevention of lymphedema and simultaneous immediate autologous breast reconstruction without the risk of iatrogenic lymphedema. Further studies will be directed to unveil the external validity of these findings and the risk reduction rate of this approach.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Jessica Gutierrez-Arana
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Horacio F Mayer
- Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
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23
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Dual Fluorescent Tracers for Surgical Guidance: Preventing Donor-site Lymphedema in Vascularized Lymph Node Transfer. Plast Reconstr Surg Glob Open 2022; 10:e4390. [PMID: 35919888 PMCID: PMC9278919 DOI: 10.1097/gox.0000000000004390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/04/2022] [Indexed: 11/26/2022]
Abstract
Introduction: Vascularized lymph node transfer (VLNT) restores physiological lymphatic function. Although effective, postoperative impairment of donor-site lymphatic function and iatrogenic lymphedema following lymph node transfer remains a pressing concern. Methods: Prospective analysis of VLNT patients undergoing dual fluorescent tracers-assisted harvest was performed at our institution from September 2013 to April 2022. Reverse lymphatic mapping of the lower extremity was performed with indocyanine green (ICG). Blue dye was utilized in both white light and near-infrared spectra for visualization of donor-site lymphatic structures. Demographics, intraoperative details, and surgical outcomes were recorded. Results: Twenty-five patients were included. Median age was 52.9 years with a body mass index of 29.1 kg/m2 and mean follow-up of 44 months (range 24 to 90 months). Lymphedema stage ranged from Campisi 2 to 4. Inguinal VLNT was performed in 13 patients, and 12 patients received combined VLNT and free flap breast reconstruction. No patients required change in lymph node donor site intraoperatively. All ICG stained nodes were preserved in situ. No cases of iatrogenic lower extremity lymphedema were observed. Postoperative bioimpedance spectroscopy, circumferential, and volumetric measurements of the donor-site limb did not show evidence of subclinical or clinical lymphedema. The donor site healed appropriately in 92% of patients; one patient developed methylene blue-induced skin necrosis. Conclusion: Reverse lymphatic mapping and surgical guidance with dual ICG and blue dye fluorescent tracers provides surgeons with real-time surgical guidance without radioisotope, improves surgical visualization in both white light and near-infrared spectra, and avoids iatrogenic lymphatic dysfunction in the donor limb.
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Wang H, Dong D, Liu C, Yuan M, Chen L, Liu T. The Effects of Methylene Blue and Carbon Nanoparticles on Transplanted Lymph Node Survival, Reconstructed Lymphatic Function, and Changes in Inflammatory and Fibrosis Factors. World J Surg 2022; 46:2166-2173. [PMID: 35618946 DOI: 10.1007/s00268-022-06594-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Methylene blue (MB) and carbon nanoparticles (CNs) can be used as a simple method for reverse lymphatic mapping. We investigated whether the two tracers had an impact on the survival of lymph nodes and the function of reconstructed lymph vessels after transplantation, as well as the changes in surrounding related factors. METHODS The stained lymph nodes were non-vascularized transplanted into the contralateral popliteal fossa in mice. After 4 weeks, the lymphatic recanalization was detected. The samples were harvested for pathological detection and PCR. In addition, the transport ability of the recanalized lymphatics to tumor cells was also explored. RESULTS Compared with the control group, there was no significant difference of the MB and CNs groups in the drainage function of recanalized lymphatic vessels, the survival of lymph nodes, or the transport capacity to tumor cells. TNF-α and IL-6 were significantly higher in the two tracer groups (**p < 0.01). Besides, the α-SMA was significantly increased in the CNs group (*p < 0.05). CONCLUSIONS Two tracers have no effect on the survival of transplanted lymph nodes, nor do they affect the drainage ability or tumor cell capture ability of the reconstructed lymphatics, despite improving TNF-α and IL-6 levels and the deposition of CNs.
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Affiliation(s)
- Heng Wang
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Dong Dong
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Chi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Mingjie Yuan
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Liang Chen
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Tianyi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
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Luzardo González A, Planas Balagué R, Gómez Cuba M, Fernández Mariscal E, Arencibia Domínguez A, Salinas Huertas S. [Rehabilitation in lymphedema surgery]. Rehabilitacion (Madr) 2022; 56:215-225. [PMID: 35527077 DOI: 10.1016/j.rh.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/29/2021] [Accepted: 12/11/2021] [Indexed: 01/25/2023]
Abstract
Conservative treatment of lymphedema usually includes complex decongestive therapy in order to reduce the volume of the lymphedema, and compression garments in the maintenance phase. Follow-up is carried out in the Rehabilitation Services. Surgical treatment of lymphedema is a therapeutic option, the interest of which has increased in recent years, although there is no current evidence that it can cure lymphedema and it is always accompanied by conservative treatment. Most studies focus on results according to the type of surgery and there is no standardized protocol for conservative treatment before or after surgery. The objective of this work is to prepare a compendium about the most frequent lymphedema surgeries and their indications, focusing on the rehabilitation treatment for each surgery.
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Affiliation(s)
- A Luzardo González
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - R Planas Balagué
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - M Gómez Cuba
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España; Universitat de Barcelona, Barcelona, España
| | - E Fernández Mariscal
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - A Arencibia Domínguez
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - S Salinas Huertas
- Medicina Física y Rehabilitación, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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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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Coroneos CJ, Asaad M, Wong FC, Hall MS, Chen DN, Hanasono MM, Schaverien MV. Outcomes and technical modifications of vascularized lymph node transplantation from the lateral thoracic region for treatment of lymphedema. J Surg Oncol 2022; 125:603-614. [PMID: 34989418 DOI: 10.1002/jso.26783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/19/2021] [Accepted: 12/13/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND AND OBJECTIVES This study evaluates clinical outcomes of vascularized lymph node transplantation (VLNT) from the lateral thoracic region and technical modifications. METHODS Consecutive patients that underwent lateral thoracic VLNT to treat extremity lymphedema were included. Demographic and treatment data were recorded, and outcomes data including limb volume, LDex score, and Lymphedema Life Impact Scale (LLIS), QuickDASH, and LEFS questionnaires, were collected prospectively. Consecutive patients that underwent single-photon emission computed tomography (SPECT/CT) lymphoscintigraphy axillary reverse lymphatic mapping (RLM) were analyzed to characterize the physiological drainage of the normal upper extremity. RESULTS A consecutive series of 32 flaps were included. At 24 months postoperatively mean reduction in limb volume excess was 47.2% (±11.6; p = 0.0085), LDex score was 63.1% (±8.5; p < 0.001), and LLIS score was 65.1% (±7.4; p < 0.001). Preoperatively 14/31 patients (45.2%) reported cellulitis, and postoperatively there were no episodes at up to 24 months (p < 0.001). No patient developed donor extremity lymphedema at mean 18.6 (±8.3) months follow-up. SPECT/CT-RLM of 182 normal axillae demonstrated that the sentinel lymph node(s) of the upper extremity was consistently anatomically located in the upper outer quadrant of the axilla (97%). CONCLUSIONS VLNT from the lateral thoracic region is effective and versatile for the treatment of lymphedema with a low donor site complication rate.
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Affiliation(s)
- Christopher J Coroneos
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Malke Asaad
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Franklin C Wong
- Division of Diagnostic Imaging, Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa S Hall
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dawn N Chen
- Department of Rehabilitation Services, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Goldman C, Lee H, Tom L, Krasnow R. Microsurgical treatment of lower extremity lymphedema: A multidisciplinary approach to improve morbidity in advanced penile cancer patients. Urol Oncol 2022; 40:113.e1-113.e8. [PMID: 35042662 DOI: 10.1016/j.urolonc.2021.11.011] [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] [Received: 08/15/2021] [Revised: 10/13/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Lower extremity lymphedema is a major source of morbidity in up to 70% of penile cancer patients. Lymphedema is often thought to be incurable, though surgical treatments have started to emerge. This study is the first to apply lymphovenous bypass specifically to penile cancer patients status post lymphadenectomy. METHODS We performed microsurgical lymphovenous bypass in 3 patients who underwent inguinal lymphadenectomy for advanced penile cancer, and later lymph node transplant in 1 patient. RESULTS The lymphovenous bypass was performed by a trained microsurgeon: Two patients were treated as outpatients for lymphedema, and 1 patient underwent prophylactic lymphovenous bypass simultaneously with initial lymphadenectomy. We saw significant improvement in patient's clinical lymphedema as well as lymphatic drainage on infared imaging for 2 of 3 patients at 12 months, however 1 of these patients did require later lymph node transfer at 24 months. CONCLUSION This early proof of concept study shows that these procedures should be considered and studied further in the treatment and prevention of debilitating lymphedema in the penile cancer population.
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Affiliation(s)
- Charlotte Goldman
- MedStar Georgetown University Hospital Department of Urology, Washington, DC.
| | - Harry Lee
- Georgetown University School of Medicine, Washington, DC
| | - Laura Tom
- MedStar Washington Hospital Center Department of Plastic Surgery, Washington, DC
| | - Ross Krasnow
- MedStar Washington Hospital Center Department of Urology, Washington, DC
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29
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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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30
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Maldonado AA, Ramos E, García-Alonso P, Jover JJ, Holguín P, Fernández-Cañamaque JL, Cristóbal L. [Multidisciplinary approach in the lymphedema patient: From rehabilitation to microsurgery]. Rehabilitacion (Madr) 2021; 56:150-158. [PMID: 34538653 DOI: 10.1016/j.rh.2021.06.003] [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: 11/08/2020] [Revised: 02/02/2021] [Accepted: 06/11/2021] [Indexed: 10/20/2022]
Abstract
Lymphedema is a chronic disease with a high incidence in our society. In this paper, we present a review with the latest advances in imaging techniques and surgical reconstructive treatment of lymphedema (lymphovenous anastomosis, vascularized lymph node transfer, and prophylactic lymphedema surgery). In addition, a protocol is established based on a multidisciplinary team (composed of physiatrists, plastic surgeons, radiologists and nuclear medicine radiologists) to optimize the treatment of these patients.
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Affiliation(s)
- A A Maldonado
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España; Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center Frankfurt am Main, Academic Hospital of the Goethe University Frankfurt am Main, Frankfurt am Main, Frankfurt, Alemania.
| | - E Ramos
- Departamento de Rehabilitación, Hospital Universitario Getafe, Getafe (Madrid), España
| | - P García-Alonso
- Departamento de Medicina Nuclear, Hospital Universitario Getafe, Getafe (Madrid), España
| | - J J Jover
- Departmento de Radiología, Hospital Universitario Getafe, Getafe (Madrid), España
| | - P Holguín
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España
| | | | - L Cristóbal
- Departamento de Cirugía Plástica, Hospital Universitario Getafe, Getafe (Madrid), España
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31
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A Systematic Review and Meta-Analysis of Vascularised Lymph Node Transfer for Breast Cancer Related Lymphedema. J Vasc Surg Venous Lymphat Disord 2021; 10:786-795.e1. [PMID: 34508873 DOI: 10.1016/j.jvsv.2021.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Vascularized lymph node transfer (VLNT) is an increasingly popular technique for treating lymphedema. However, while many studies have been performed, its efficacy to increase patients' quality of life and reduce lymphedema in the affected body part are still controversial. In this systematic review we summarize the evidence on VLNT for treating breast cancer related lymphedema (BCRL). MATERIAL AND METHODS MEDLINE, EMBASE and Cochrane CENTRAL were searched for studies including patients with BCRL who received VLNT. Methodology was assessed by the MINORS tool. Primary outcomes were change in volume difference between arms and quality of life. Secondary outcomes were skin infections, complications and discontinuation of compression garment use. RESULTS 17 Studies were included for qualitative synthesis and eight studies for meta-analysis. The average reduction rate between the healthy and affected arm for studies included in the meta-analysis was 40.31%. Five studies evaluated QoL and in all of these studies QoL was significantly increased. Eight studies evaluated skin infections of which three provided yearly infection rates before and after surgery. In these studies infection rate was significantly decreased. Three studies described usage of compression garment. When patients are pooled 27 out of 60 were able to discontinue compression garment. Donor and recipient complication rates were 12.1 and 7.3% respectively. CONCLUSIONS Current evidence indicates that VLNT can improve volume difference between arms in unilateral lymphedema patients by about 40%. In addition, although based on few studies, it is likely that VLNT has a positive effect on patients QoL, the number of skin infections and compression garment usage while coinciding with a low complication rate.
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32
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Complete lymphatic restoration by simultaneous vascularized lymph node and lymphatic vessel transplantation. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01865-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Reverse Lymph Node Mapping Using Indocyanine Green Lymphography: A Step Forward in Minimizing Donor-Site Morbidity in Vascularized Lymph Node Transfer. Plast Reconstr Surg 2021; 147:207e-212e. [PMID: 33565822 DOI: 10.1097/prs.0000000000007585] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Reverse lymphatic mapping before harvesting a lymph node flap is crucial to avoid donor-site lymphedema; however, the technique is complex and unavailable in many centers. The authors introduce radioisotope-free reverse lymphatic mapping using indocyanine green and Patent Blue dye. METHODS The authors conducted a prospective study in patients undergoing free vascularized groin lymph node transfer for postmastectomy upper extremity lymphedema. The day before surgery, 0.2 ml of technetium-99 was injected into the first and second web spaces of the ipsilateral foot. The following day, once the patient was anesthetized, indocyanine green was injected into the same web spaces of the same foot and Patent Blue dye was injected just proximal to the upper margin of the skin paddle of the lymph node flap. The main lymph nodes draining the limb were localized using indocyanine green lymphography and gamma probe. RESULTS Thirty-nine patients underwent vascularized groin lymph node transfer with or without deep inferior epigastric artery perforator flap breast reconstruction. Navigation of the main lower extremity draining inguinal lymph nodes using the gamma probe and indocyanine green lymphography was identical in all patients. The blue-stained lymphatics in the skin paddle drained to the superficial proximal inguinal lymph node and were targeted for transfer. No donor-site lymphedema was reported, and lymphatic drainage of the lower extremity was preserved in all cases. CONCLUSIONS Reverse lymphatic mapping using indocyanine green lymphography provides identical results to those using technetium-99 isotope scanning. However, indocyanine green is preferable in terms of safety and reproducibility and also avoids the complexity and hazards of radioisotope mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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34
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Kueckelhaus M, Gebur N, Kampshoff D, Hiort M, Varnava C, Harati K, Hirsch T, Wiebringhaus P. Initial experience with the superficial circumflex iliac artery perforator (SCIP) flap for extremity reconstruction in Caucasians. J Plast Reconstr Aesthet Surg 2021; 75:118-124. [PMID: 34509392 DOI: 10.1016/j.bjps.2021.05.069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/20/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The superficial circumflex iliac artery perforator (SCIP) flap has been established in Asia to provide an excellent option for soft tissue defect coverage. The main advantage of this delicate flap is its very thin design. However, the adoption of this technique in other parts of the world has been rarely reported. METHODS In this retrospective study, we analyzed outcomes of 32 SCIP flaps in a Caucasian patient population. The procedures were performed at our institution between March 2019 and August 2020. We present patient characteristics, surgical technique, perioperative care, and flap applications as compared to the Asian approaches. RESULTS Patients' average BMI was 28.7. Flap anatomy and flap thickness at the superficial fascial plane differed significantly within our population. With 1.7 mm on average, the arterial diameter was higher than reported in the literature. Flaps were based on an axial perforator in 52% of cases. The SCIP flap was performed safely in the majority of cases. The surgical flap elevation approach was modified toward speedy perforator identification. CONCLUSIONS The SCIP flap offers superior opportunities for thin soft tissue defect coverage with excellent functional outcomes in Caucasian patients. Based on higher BMI and anatomical differences as compared to Asian patient populations, modifications of flap elevation were necessary to increase reliability. More outcome reports from outside Asia need to become available to advance SCIP flap application internationally.
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Affiliation(s)
- Maximilian Kueckelhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany.
| | - Nils Gebur
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - David Kampshoff
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Mirkka Hiort
- Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Charalampos Varnava
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Kamran Harati
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Tobias Hirsch
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
| | - Philipp Wiebringhaus
- Division of Plastic Surgery, Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Muenster, Germany; Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Fachklinik Hornheide, Muenster, Germany; Institute of Musculoskeletal Medicine, University Hospital Muenster, Germany
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Abstract
Lymphedema is a common, complex, and inexplicably underappreciated human disease. Despite a history of relative neglect by health care providers and by governmental health care agencies, the last decade has seen an explosive growth of insights into, and approaches to, the problem of human lymphedema. The current review highlights the significant advances that have occurred in the investigative and clinical approaches to lymphedema, particularly over the last decade. This review summarizes the progress that has been attained in the realms of genetics, lymphatic imaging, and lymphatic surgery. Newer molecular insights are explored, along with their relationship to future molecular therapeutics. Growing insights into the relationships among lymphedema, obesity, and other comorbidities are important to consider in current and future responses to patients with lymphedema.
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Affiliation(s)
- Stanley G Rockson
- Allan and Tina Neill Professor of Lymphatic Research and Medicine, Stanford University School of Medicine, Stanford, CA
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36
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Ward J, King I, Monroy-Iglesias M, Russell B, van Hemelrijck M, Ramsey K, Khan AA. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer 2021; 151:233-244. [PMID: 34092349 DOI: 10.1016/j.ejca.2021.02.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness. AIM The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL). METHODS PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed. RESULTS Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRRP] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRRP = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRRP = 46.8% [95% CI: 43.2-50.4]; below knee CRRP = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRRP = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRRP = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRRP = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26). CONCLUSIONS VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.
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Affiliation(s)
- Joseph Ward
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ian King
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Maria Monroy-Iglesias
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Beth Russell
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Mieke van Hemelrijck
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Kelvin Ramsey
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aadil A Khan
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
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Patient-specific surgical options for breast cancer-related lymphedema: technical tips. Arch Plast Surg 2021; 48:246-253. [PMID: 34024068 PMCID: PMC8143939 DOI: 10.5999/aps.2020.02432] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/09/2021] [Indexed: 11/08/2022] Open
Abstract
In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient's pathology, the treatment plan should be carefully decided and individualized. At the authors' institution, the treatment plan is made individually based on each patient's symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient's pathophysiology, optimal outcomes can be achieved. Depending on each patient's pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.
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Seventy-Fifth Anniversary of Plastic and Reconstructive Surgery: How Evidence-Based Medicine Has Transformed Plastic Surgery. Plast Reconstr Surg 2021; 147:1235-1241. [PMID: 33890912 DOI: 10.1097/prs.0000000000007913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Akita S, Yamaji Y, Tokumoto H, Tezuka T, Ogata H, Kosaka K, Kanai M, Kuriyama M, Mitsukawa N. Where does subcutaneous lymph from the chest wall flow into after mastectomy? J Plast Reconstr Aesthet Surg 2021; 74:2856-2862. [PMID: 34020906 DOI: 10.1016/j.bjps.2021.03.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/05/2021] [Accepted: 03/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Changes of the lymph flow from the chest wall after mastectomy and sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (Ax) has yet to be understood. This study aimed to investigate the effect of axillary surgery on lymphatic flow from the chest wall in patients who have undergone mastectomy, including those have undergone breast reconstruction and vascularized lymph node transfer (VLNT). METHODS Following mastectomy in 100 breasts, the directions of lymph flow from the chest wall was compared between the SLNB omission, SLNB, Ax, and Ax followed by VLNT groups using indocyanine green (ICG) lymphography in cross-sectional study. Lymph flow on the deep epigastric artery perforator (DIEP) flap was also investigated. RESULTS Lymph flow directing to the ipsilateral axilla was observed more frequently after SLNB than Ax (48% vs. 12.5%; p = 0.005); however, no significant difference was observed in the frequency of contralateral axillary route adoption between them (8% vs. 15%; p = 0.65). In the VLNT group, lymph flow to the ipsilateral axilla was not observed at a significantly higher frequency than in the Ax group (12.5% vs. 12.5%, p = 1.00). On the transferred DIEP flap, the lymph flowed anterograde or retrograde parallel to the anatomic course of the lymphatic vessels. CONCLUSION To visualize the direction of lymph flow of the chest following mastectomy, ICG lymphography may be useful to discern the direction in which malignant neoplasms, including lymphoma, are transported and to plan for lymph flow restoration.
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Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan.
| | - Yoshihisa Yamaji
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Takafumi Tezuka
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hideyuki Ogata
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kentaro Kosaka
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masahiko Kanai
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motone Kuriyama
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan; Department of Plastic and Reconstructive Surgery, Shinyurigaoka General Hospital, Kawasaki, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis. J Plast Reconstr Aesthet Surg 2021; 74:2604-2612. [PMID: 33867280 DOI: 10.1016/j.bjps.2021.03.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/01/2021] [Accepted: 03/11/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Lymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. METHODS Medical charts of 122 free flap reconstruction cases, either with conventional flap transfer (control) or lymph-interpositional-flap transfer (LIFT), for extremity soft tissue defects including lymphatic pathways were reviewed. Lymph vessels' stumps in a flap were placed as close to those in a recipient site as possible under indocyanine green (ICG) lymphography navigation in LIFT group. LIFT group was subdivided into LIFT(+) and LIFT(-) groups; lymph vessels' stumps could be approximated within 2 cm in LIFT(+) group, whereas those could not be in LIFT(-) group. Lymph flow restoration (LFR) and lymphedema development (LED) rates were compared between the groups on postoperative 6 months. RESULTS No flap included lymph node. LFR was observed in 50 cases and LED in 72 cases. LFR rate in LIFT group (n = 75) was significantly higher than that in control group (n = 47) (57.3% vs. 14.9%; P < 0.001). LED rate in LIFT group was significantly lower than that in control group (20.0% vs. 48.9%; P < 0.001). Sub-group analysis showed significantly higher LFR and lower LED rates in LIFT(+) group (n = 44) than those in LIFT(-) group (n = 31; 88.6% vs. 12.9%; P < 0.001, 4.5% vs. 41.9%; P < 0.001). CONCLUSIONS LIFT allows simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis, which prevents development of secondary lymphedema.
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Schaverien MV, Asaad M, Selber JC, Liu J, Chen DN, Hall MS, Butler CE. Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema. J Am Coll Surg 2021; 232:982-994. [PMID: 33766726 DOI: 10.1016/j.jamcollsurg.2021.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/18/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND A growing body of evidence supports the efficacy of surgical treatments for lymphedema. This study reports the outcomes of vascularized lymph node transplantation (VLNT) for the treatment of patients with lymphedema compared with maximal conservative treatment alone. STUDY DESIGN Consecutive patients undergoing VLNT to treat primary and secondary lymphedema affecting the upper or lower extremities were included. All patients were optimized preoperatively with conservative therapy. Demographic and treatment information was collected, and outcomes data were electronically captured prospectively; descriptive statistics were performed. RESULTS There were 134 patients included that had achieved maximal reductions by conservative therapy preoperatively. This series included jejunal mesenteric (n = 25), groin (n = 43), lateral thoracic (n = 31), omental or right gastroepiploic (n = 21), and submental (n = 14) VLN flaps. At 24 months postoperatively, there were significant reductions in limb volume change (mean [SD] 45.7% [8.7%]; p = 0.002) LDex score (mean [SD] 59.8% [8.7%]; p < 0.001), Lymphedema Life Impact Scale score (mean [SD] 61.6% [5.9]; p < 0.001), and cellulitis episodes (97.9%; p < 0.001). At 3 and 6 months postoperatively, limb volume change was significantly greater for the upper than the lower extremity, otherwise outcomes were similar. There were no flap losses and overall outcomes were similar between the different VLN flap types. CONCLUSIONS Treatment of lymphedema using VLNT resulted in progressive, significant reductions in limb volume, bioimpedance spectroscopy measurements of extracellular fluid, and episodes of cellulitis, with improved patient-reported outcomes and limb function measures compared with maximal conservative therapy alone. The complication rate was low and there were no significant outcomes differences between the VLNT types.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Malke Asaad
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jesse C Selber
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jun Liu
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Dawn N Chen
- Rehabilitation Services, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Melissa S Hall
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Charles E Butler
- Department of Plastic Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Chen K, Sinelnikov MY, Shchedrina MA, Mu L, Lu P. Surgical Management of Postmastectomy Lymphedema and Review of the Literature. Ann Plast Surg 2021; 86:S173-S176. [PMID: 33346539 DOI: 10.1097/sap.0000000000002642] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
ABSTRACT Upper limb lymphedema is one of the most common complications after breast cancer surgery and radiotherapy. At present, physical methods and surgical methods can be used for treatment. Surgical operations are mainly based on lymphovenous anastomosis and vascularized lymph node transfer. For these 2 surgical methods, we analyzed and compared the literature review and our own clinical experience. We summarized the differences between the 2 surgical techniques and the selection methods. We hope to help more young plastic surgeons and breast doctors understand how to treat upper limb lymphedema through surgical methods and help patients improve their quality of life.
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Affiliation(s)
- Kuo Chen
- From the The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | | | | | - Lan Mu
- Hainan Tumor Hospital, Haikou, China
| | - Pengwei Lu
- From the The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Skladman R, Anolik RA, Sacks JM. State-of-the-Art Lymphedema Surgery Treatment Program. MISSOURI MEDICINE 2021; 118:134-140. [PMID: 33840856 PMCID: PMC8029635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The purpose of this article is to describe the multidisciplinary lymphedema surgery treatment program at Washington University in St. Louis. In this article, we discuss our collaboration with colleagues in medicine and therapy for conservative management and lymphedema staging. We describe our preferred imaging modalities for diagnosis, staging, and surgical treatment. Finally, we provide an overview of the surgical procedures we perform and our surgical treatment algorithm.
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Affiliation(s)
- Rachel Skladman
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Rachel A Anolik
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
| | - Justin M Sacks
- Division of Plastic and Reconstructive Surgery, Washington University, St. Louis, Missouri
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Hanson SE, Chu CK, Chang EI. Surgical Treatment Options of Breast Cancer-Related Lymphedema. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00286-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Schaverien MV, Chang EI. Combined deep inferior epigastric artery perforator flap with vascularized groin lymph node transplant for treatment of breast cancer-related lymphedema. Gland Surg 2021; 10:460-468. [PMID: 33634003 DOI: 10.21037/gs.2020.02.14] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
For survivors of breast cancer lymphedema is their greatest survivorship burden. Modern surgical techniques to treat lymphedema are effective at reducing limb volume, symptoms of lymphedema, episodes of cellulitis, and improving patient quality of life. Physiologic procedures, including lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT), restore physiological lymphatic function within the affected extremity. In patients with post-mastectomy breast cancer-related upper extremity lymphedema that desire breast reconstruction, microvascular abdominal flap breast reconstruction can be combined with superficial inguinal (groin) VLNT to provide breast reconstruction and treatment of lymphedema in a single operation. This article reviews the indications, preoperative assessment, surgical technique, outcomes, and tips and pearls for performing this procedure.
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Affiliation(s)
- Mark V Schaverien
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Edward I Chang
- Division of Surgery, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Technical Challenges in "Micro" Lymph Node Identification during Vascularized Submental Lymph Node Flap Harvesting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3330. [PMID: 33425628 PMCID: PMC7787339 DOI: 10.1097/gox.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
Background: The outcome of autologous lymph node (LN) transfer has depended on the number of LNs in the donor site. Unknown accuracy of the LN counting method has thrown some doubts on the reliability of the previous statistics. This study aimed to assess the accuracy of naked eye (NK) and stereo microscopy (SM) as tools for LN count. Methods: In total, 40 vascularized submental LN flaps were harvested from 23 fresh cadavers. The colored polymer was injected into the external carotid arteries before the harvest. LNs in each flap were counted by NK, SM, and histology in sequential order. Results: An estimated 175 LNs were confirmed, 4.4 ± 1.8 per flap. NK sensitivity was 33.7% compared with that of SM at 63.5%. Both methods missed all micro-lymph nodes (micro-LNs), contributing to 5.1% (9 nodes) of all LNs. Non-LN structures (647 negative counts) were composed of fat lobules, salivary gland lobules, and muscle fibers. NK specificity was 98.0%, compared with that of SM at 96.1%. SM showed a higher false positive rate at 14.3%, compared with NK at 7.4%. False positive counts were located mostly in Ib sublevel. Conclusions: NK and SM are imperfect tools for LN count due to poor sensitivity. If the method needs to be applied, points of considerations are (1) undetectable micro-LNs, (2) interposition of LNs with the digastric muscle and submandibular salivary gland, (3) confusion of LNs with lobules of salivary gland supplied by glandular artery or fat lobules supplied by lobular artery.
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McLaughlin SA, Stout NL, Schaverien MV. Avoiding the Swell: Advances in Lymphedema Prevention, Detection, and Management. Am Soc Clin Oncol Educ Book 2020; 40:1-10. [PMID: 32315238 DOI: 10.1200/edbk_280471] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Lymphedema is a feared complication of cancer treatments that negatively affects survivors' quality of life. The true incidence of lymphedema is difficult to determine given its long latency period. As the number of survivors of cancer is increasing in the United States, lymphedema is poised to be a major health concern. The most noteworthy risk factor for lymphedema is comprehensive lymph node dissection. The last 2 decades have witnessed a dramatic shift in cancer treatment in an attempt to systematically de-escalate therapeutic interventions, specifically seeking to shift treatment away from routine lymph node dissection in favor of sentinel node biopsy or radiation strategies, thereby reducing the risk for lymphedema while maintaining survival outcomes. A growing body of robust evidence supports prospective screening and thereby a prospective surveillance model (PSM) for early diagnosis and intervention for the prevention and treatment of lymphedema. Finally, investigators are actively evaluating the effectiveness of contemporary surgical procedures in ameliorating the symptoms and disability of patients with lymphedema and reducing the risk of future episodes of cellulitis, with outcomes of surgery significantly better than with conservative therapy alone. In this article, we review the current data surrounding these initiatives.
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Affiliation(s)
| | - Nicole L Stout
- Department of Hematology Oncology, West Virginia University Cancer Institute, Morgantown, WV
| | - Mark V Schaverien
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
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Aesthetic Applications of Radiofrequency: Lymphatic and Perfusion Assessment. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3193. [PMID: 33173697 PMCID: PMC7647541 DOI: 10.1097/gox.0000000000003193] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 08/18/2020] [Indexed: 12/03/2022]
Abstract
Background: The use of radiofrequency in aesthetics has increased in popularity since the early 2000s. To date, there have been limited studies investigating the effect of thermal energy secondary to radiofrequency treatment. The purpose of this study was to evaluate perfusion and lymphatic assessment tools pre and post bipolar and fractional radiofrequency treatment. Methods: A retrospective IRB-approved study was conducted between January 2019 and April 2019. Patients who were independently deemed appropriate candidates for radiofrequency soft tissue remodeling were evaluated. Diagnostic perfusion and lymphatic imaging obtained were reviewed using indocyanine green (SPY, Stryker) and optical coherence tomography (Vivosight OCT). Results: A total of 63 patients were treated during the study period, of which 37 had diagnostic perfusion and lymphatic imaging. Average patient age was 47 (STD 12), 95% (35/37) of patients were women, and no patients were active smokers. In total, 27% (10/37) of patients were post-surgical patients with recurrent laxity, 32% (12/37) did not have enough skin laxity to justify traditional excisions procedures, and 41% (15/37) may have been candidates for excisional procedures but were willing to accept more moderate results to avoid excisions surgery. Indocyanine green perfusion and lymphatic assessment for bipolar and fractional radiofrequency, as well as optical coherence tomography pre and post radiofrequency, did not show compromise from thermal injury. Conclusions: This study supports safety of radiofrequency in terms of preservation of tissue perfusion and lymphatic drainage. This correlated to our low clinical incidence of burns, prolonged swelling, or tissue ischemia.
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Response to: Comparisons of Submental and Groin Vascularized Lymph Node Flaps Transfer for Breast Cancer-related Lymphedema. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2749. [PMID: 33133926 PMCID: PMC7544281 DOI: 10.1097/gox.0000000000002749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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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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