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Garza RM, Wong D, Chang DW. Optimizing Outcomes in Lymphedema Reconstruction. Plast Reconstr Surg 2023; 152:1131e-1142e. [PMID: 38019691 DOI: 10.1097/prs.0000000000010965] [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: 12/01/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. SUMMARY Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.
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Affiliation(s)
- Rebecca M Garza
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - Daniel Wong
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
| | - David W Chang
- From the Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago Medicine & Biological Sciences
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2
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Chiu A, Jia W, Sun Y, Goldman J, Zhao F. Fibroblast-Generated Extracellular Matrix Guides Anastomosis during Wound Healing in an Engineered Lymphatic Skin Flap. Bioengineering (Basel) 2023; 10:bioengineering10020149. [PMID: 36829643 PMCID: PMC9952048 DOI: 10.3390/bioengineering10020149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/04/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
A healthy lymphatic system is required to return excess interstitial fluid back to the venous circulation. However, up to 49% of breast cancer survivors eventually develop breast cancer-related lymphedema due to lymphatic injuries from lymph node dissections or biopsies performed to treat cancer. While early-stage lymphedema can be ameliorated by manual lymph drainage, no cure exists for late-stage lymphedema when lymph vessels become completely dysfunctional. A viable late-stage treatment is the autotransplantation of functional lymphatic vessels. Here we report on a novel engineered lymphatic flap that may eventually replace the skin flaps used in vascularized lymph vessel transfers. The engineered flap mimics the lymphatic and dermal compartments of the skin by guiding multi-layered tissue organization of mesenchymal stem cells and lymphatic endothelial cells with an aligned decellularized fibroblast matrix. The construct was tested in a novel bilayered wound healing model and implanted into athymic nude rats. The in vitro model demonstrated capillary invasion into the wound gaps and deposition of extracellular matrix fibers, which may guide anastomosis and vascular integration of the graft during wound healing. The construct successfully anastomosed in vivo, forming chimeric vessels of human and rat cells. Overall, our flap replacement has high potential for treating lymphedema.
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Affiliation(s)
- Alvis Chiu
- Stem Cell and Tissue Engineering Lab, Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, TX 77843, USA
| | - Wenkai Jia
- Stem Cell and Tissue Engineering Lab, Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, TX 77843, USA
| | - Yumeng Sun
- Stem Cell and Tissue Engineering Lab, Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, TX 77843, USA
| | - Jeremy Goldman
- Vascular Materials Lab, Department of Biomedical Engineering, College of Engineering, Michigan Technological University, Houghton, MI 49931, USA
| | - Feng Zhao
- Stem Cell and Tissue Engineering Lab, Department of Biomedical Engineering, College of Engineering, Texas A&M University, College Station, TX 77843, USA
- Correspondence:
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3
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Winters H, Tielemans H, Hummelink S, Slater N, Ulrich D. DIEP flap breast reconstruction combined with vascularized lymph node transfer for patients with breast cancer-related lymphedema. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1718-1722. [DOI: 10.1016/j.ejso.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
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4
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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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5
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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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Ciudad P, Huayllani MT, Forte AJ, Boczar D, Avila FR, Escandón JM, Manrique OJ, Chen HC. Vascularized Lymph Node Transfer for the Treatment of Posttraumatic Lower Extremity Lymphedema: A Preliminary Report. Indian J Plast Surg 2022; 55:97-101. [PMID: 35444749 PMCID: PMC9015821 DOI: 10.1055/s-0041-1740520] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background
Posttraumatic lymphedema develops more frequently than expected and reports on its management are scarce in the literature. We aimed to report the clinical outcomes of a case series of posttraumatic lymphedema patients treated with different vascularized lymph node transfers (VLNTs).
Patients and Methods
Five patients with secondary posttraumatic lower limb lymphedema treated with VLNT were included in this report. The groin-VLNT (
n
= 1), supraclavicular-VLNT (
n
= 2), and gastroepiploic-VLNT (
n
= 2) were implemented. The average flap area was 69.8 cm
2
. Patients underwent postoperative complex decompressive therapy for an average of 10.0 months.
Results
The average mean circumference reduction rate was 24.4% (range, 10.2–37.6%). Postsurgical reduction in the number of infection episodes per year was observed in all patients. The mean follow-up was 34.2 months.
Conclusions
VLNT is a promising surgical treatment for posttraumatic lymphedema patients. In our report, VLNT has demonstrated to reduce the volume and number of infections per year in posttraumatic lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Maria T. Huayllani
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Antonio J. Forte
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Daniel Boczar
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Francisco R. Avila
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, United States
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Bolletta A, di Taranto G, Losco L, Elia R, Sert G, Ribuffo D, Cigna E, Chen HC. Combined lymph node transfer and suction-assisted lipectomy in lymphedema treatment: A prospective study. Microsurgery 2022; 42:433-440. [PMID: 34994481 DOI: 10.1002/micr.30855] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Recent studies have analyzed the combination of suction-assisted lipectomy (SAL) and vascularized lymph node transfer (VLNT) in lymphedema treatment, reporting positive outcomes. However, it is difficult to draw conclusions due to the heterogeneity of the studies. Aim of this prospective study is to evaluate the effectiveness of the combination of VLNT and SAL in lymphedema treatment. PATIENTS AND METHODS Between January 2016 and May 2019, 94 patients with upper or lower limb stage IIb-III lymphedema were enrolled and treated with the gastroepiploic VLNT followed by SAL. Patients were prospectively evaluated through circumference measurement and clinical examination, including number of episodes of cellulitis. RESULTS Among patients enrolled in the study 83 were affected by lower limb lymphedema (LLL) and 11 were affected by upper limb lymphedema (ULL). Average follow-up was 3 ± 0.8 years. In the LLL group, the mean circumference reduction rates (CRR) were 60.4, 56.9, 29.6, and 55.4% above and below the knee, above the ankle, and at the foot level, respectively. A statistically significant difference was noted at all the levels (p < .05), but above the ankle (p = .059). Regarding the ULL group, the mean CRR were 80.7, 60.7, 65.0 and 49.6% above and below the elbow, at wrist and at mid-hand, respectively. CRR were reported at all the levels but no statistical difference was noted. The number of episodes of cellulitis dropped significantly (p < .05). CONCLUSION This study supports the use of VLNT+SAL in lymphedema grades IIb-III, with important implications for the clinical practice.
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Affiliation(s)
- Alberto Bolletta
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Giuseppe di Taranto
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Luigi Losco
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Rossella Elia
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.,Unit of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gokhan Sert
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Diego Ribuffo
- Plastic Surgery Unit, Department of surgery, Sapienza University of Rome, Italy
| | - Emanuele Cigna
- Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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8
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Li Y, Dong R, Li Z, Wang L, Long X. Intra-abdominal vascularized lymph node transfer for treatment of lymphedema: A systematic literature review and meta-analysis. Microsurgery 2021; 41:802-815. [PMID: 34562039 DOI: 10.1002/micr.30812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/27/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND As a promising treatment for lymphedema, vascularized lymph node transfer (VLNT) is associated with a risk of iatrogenic lymphedema. Intra-abdominal vascularized lymph node flap has been increasingly applied to minimize complication. METHODS PubMed, EMBASE, Web of Sciences, and Cochrane databases were searched systematically. Clinical articles describing the application of intra-abdominal flaps to treat lymphedema were included. Study characteristics, patient demographics, and operative details were recorded. Primary outcomes were recorded as circumference/volume reduction, episodes of cellulitis reduction and lymph flow assessment. Secondary outcomes were recorded as donor-site complication and recipient-site complication. RESULTS Twenty-one studies met the inclusion criteria with 594 patients in total. Donor-sites of flaps were omental/gastroepiploic, jejunal, ileocecal, and appendicular. The mean reduction rate ranged from 0.38% to 70.8%. Significant reduction in infectious episodes was reported in 10 studies. The pooled donor-site complication rate was 1.4% (95% CI, 0%-4.1%; I2 = 40%). The pooled recipient-site complication rate was 3.2% (95% CI, 1.4%-5.5%; I2 = 39%). The most common donor-site complication was minor ileus requiring prolonged nasogastric tube replacement. No donor site lymph disfunction occurred. CONCLUSION Intra-abdominal VLNT is an effective technique for patients with lymphedema with no obvious impairment to donor-site lymph function, as long as the operation is properly performed.
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Affiliation(s)
- Yunzhu Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Ruijia Dong
- Department of Plastic Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhujun Li
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Liquan Wang
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao Long
- Department of Plastic and Reconstructive Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg 2021; 147:975-993. [PMID: 33761519 DOI: 10.1097/prs.0000000000007783] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema. METHODS The panel met in Boston for a 3-day, face-to-face meeting in July of 2017. After an exhaustive review of the existing literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Important directions for future research were also identified. RESULTS There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C). CONCLUSIONS Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.
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10
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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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11
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Ciudad P, Chen HC, Bustos SS, Manrique OJ, Bolletta A, Forte AJ, Huayllani MT, Agko M, Urbina JA, Date S, Kaya B. The deep inferior epigastric lymphatic cable flap connected to gastroepiploic lymph node flap for treatment of refractory chylous ascites: Report of two cases. Microsurgery 2021; 41:376-383. [PMID: 33864636 DOI: 10.1002/micr.30736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 02/04/2021] [Accepted: 03/03/2021] [Indexed: 12/23/2022]
Abstract
Chylous ascites is the leakage of lipid-rich lymph into the peritoneal cavity usually due to disruption of lymphatics or increased peritoneal lymphatic pressure. Various surgical options have been proposed to treat chylous ascites but most have shown suboptimal outcomes. The gastroepiploic vascularized lymph node (GE-VLN) flap has been described previously for the treatment of lymphedema. In chylous ascites, this flap could provide an alternate drainage pathway for the intraperitoneal chylous fluid. The purpose of this report is to present another option for the microsurgical treatment of refractory chylous ascites. Herein, we report two patients with refractory chylous ascites secondary to cancer who have undergone deep inferior epigastric-based lymphatic "cable" flap (DIE-LCF) connected to a pedicle GE-VLN flap. Patients were followed-up for a minimum of 2 years. Within the first 3 months following surgery, the patient's nutritional parameters improved along with drastic reduction of ascites. At 2 years follow-up postoperative abdominal circumference decreased significantly. None required further peritoneal paracentesis and all patients were free of chylous ascites symptoms. In conclusion, the DIE-LCF connected to a pedicle GE-VLN flap could be a feasible option for the microsurgical treatment of refractory chylous ascites.
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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.,Department of Biotechnology, Experimental Surgery Unit, The Child Health's Institute (Breña), Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Antonio J Forte
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Maria T Huayllani
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Florida, Jacksonville, USA
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | | | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Padmashree Dr D Y Patil Medical College, Plastic & Reconstructive Surgery, Nerul Navi, Mumbai, India.,China Medical University Hospital, Plastic & Reconstructive Surgery, Taichung, Taiwan
| | - Burak Kaya
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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12
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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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13
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Kaya B, Ciudad P, Chen SH, Para L, Chen HC. Technical details for harvesting gastro-epiploic lymph node flaps via mini-laparotomy incision. J Plast Reconstr Aesthet Surg 2020; 73:1630-1636. [PMID: 32475737 DOI: 10.1016/j.bjps.2020.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/08/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
Laparoscopic harvest method to obtain gastro-epiploic lymph node flaps for lymphedema treatment has been previously described. In this article, the technical details of an alternative method - open approach via mini-laparotomy incision - for harvesting gastro-epiploic lymph node flaps and preparation of the flaps for the inset is presented. A total of 17 patients were included in this series of the mini-laparotomy approach. Blood loss was minimal during the surgery. The average duration of lymph node flap harvest was 65 min. The average length of hospital stay was 10 days. The period of the restricted diet was 1.5 days. The upper abdominal scar was acceptable, there were no postoperative hernia or bulging, and there were no complications related to bowel obstruction during the follow-up. The open approach harvest method via mini-laparotomy incision offers similar results to laparoscopic harvest method, and it is safe when applied with the right technique.
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Affiliation(s)
- Burak Kaya
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan; Ankara University Faculty of Medicine, Ankara, Turkey
| | - Pedro Ciudad
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | | | - Luis Para
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University and China Medical University Hospital, 2, Yuh-Der Road, Taichung 40447, Taiwan.
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14
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Ciudad P, Chen HC. Collaborative anesthesia management in patients with neuropathic pain receiving microsurgery for lymphedema. J Surg Oncol 2020; 122:567. [PMID: 32445597 DOI: 10.1002/jso.26040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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15
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Gazyakan E, Bigdeli AK, Kneser U, Hirche C. Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: A case report. Microsurgery 2020; 40:792-796. [PMID: 32259343 DOI: 10.1002/micr.30584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 01/18/2020] [Accepted: 03/20/2020] [Indexed: 11/11/2022]
Abstract
Free vascularized lymph node transfer (VLNT) is applied more and more in the treatment of lymphedema. A random-pattern skin island with VLNT is of use but can have its limitations in flap inset. We describe an option for free VLNT in the treatment of lower extremity lymphedema. We present the case of a chimeric thoracodorsal lymph node flap (TAP-VLNT) with a thoracodorsal artery perforator (TAP) flap (5 × 9 cm) to the lower leg in a 22-year old female patient with stage 2 lower leg lymphedema caused by severe traumatic skin decollement and postoperative scarring after a car accident. TAP flap enabled tailored and tension-free wound closure at the recipient site after scar release and lymph node flap inset. The anastomosis was performed to the anterior tibial artery. The postoperative course was uneventful with no complications or secondary donor-site lymphedema. Follow-up at 6 months showed reasonable cosmetic and functional outcomes. The circumference reduction rate was up to 11% and the patient reported improved quality of life. The purpose of this report is to describe a case of a more flexible lymph node flap inset and tension-free wound closure by harvesting a thin thoracodorsal artery perforator (TAP) skin island together with a thoracodorsal VLNT as a chimeric flap (TAP-VLNT) for treatment of lower extremity lymphedema. Larger series with longer follow-up data are needed to justify its widespread use and demonstrate long-term results.
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Affiliation(s)
- Emre Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Amir Khosrow Bigdeli
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, University of Heidelberg, BG Clinic Ludwigshafen, Ludwigshafen, Germany
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16
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Chang EI, Ibrahim A, Liu J, Robe C, Suami H, Hanasono MM, Nguyen AT. Optimizing Quality of Life for Patients with Breast Cancer-Related Lymphedema: A Prospective Study Combining DIEP Flap Breast Reconstruction and Lymphedema Surgery. Plast Reconstr Surg 2020; 145:676e-685e. [PMID: 32221193 DOI: 10.1097/prs.0000000000006634] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with breast cancer-related lymphedema can be treated with a simultaneous deep inferior epigastric perforator (DIEP) flap, vascularized inguinal lymph node transfer, and lymphovenous anastomosis for aesthetic breast reconstruction and lymphedema in one operation. METHODS The authors performed a comparison of prospectively followed patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer and anastomosis to a retrospective cohort of patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer alone. RESULTS Thirty-three patients underwent DIEP flap reconstruction with vascularized inguinal lymph node transfer and lymphovenous anastomosis, and 21 received a free flap with lymph node transfer alone. There were no significant differences in demographics, adjuvant chemotherapy, or radiation therapy. The average number of nodes removed was also equivalent (21.2 versus 21.4 nodes). Two anastomoses per patient, on average, were performed (range, one to four) in the combined cohort, and all patients (100 percent) reported a subjective improvement in symptoms, compared with 81.0 percent of patients undergoing only lymph node transfer (p = 0.019). Perometer measurements demonstrated a significant reduction between the groups at early time points [3 months, 40.7 percent versus 20.0 percent (p = 0.037); 6 months, 57.0 percent versus 44.5 percent (p = 0.043)]; however, the difference was not statistically significant at 12 months (60.4 percent versus 57.8 percent; p = 0.43). CONCLUSION This is the first prospective study demonstrating the safety and efficacy of a combined DIEP flap with vascularized inguinal lymph node transfer and lymphovenous anastomosis, which may be superior to lymph node transfer alone. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
- Edward I Chang
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Amir Ibrahim
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Jun Liu
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Charee Robe
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Hiroo Suami
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Matthew M Hanasono
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Alexander T Nguyen
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
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17
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Ciudad P, Forte AJ, Huayllani MT, Boczar D, Manrique OJ, Bustos SS, Bustamante A, Chen HC. Impact of body mass index on long-term surgical outcomes of vascularized lymph node transfer in lymphedema patients. Gland Surg 2020; 9:603-613. [PMID: 32420296 DOI: 10.21037/gs.2020.03.13] [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] [Indexed: 12/30/2022]
Abstract
Background Vascularized lymph node transfer (VLNT) is a surgical procedure with high interest to treat lymphedema. Body mass index (BMI) is a well-described factor that increases the risk of lymphedema, but little is known about its influence on the surgical outcomes of lymphedema patients who undergo VLNT. The aim of this study was to analyze the impact of preoperative BMI on the long-term surgical outcomes after VLNT in lymphedema patients. Methods We retrospectively compiled data of patients with International Society of Lymphology (ISL) stage II or III lymphedema who were treated with VLNT from July 2010 to July 2016 at China Medical University Hospital. Preoperative and postoperative demographic and clinical data, such as limb circumference and number of infection episodes were reviewed. Statistical analyses compared circumference reduction rates and infection episode reduction between preoperative BMI categories was done. In addition, prediction of outcomes based on quantitative preoperative BMI was analyzed. Results A total of 83 patients met the inclusion criteria. Nine patients (10.8%) were normal weight, 43 (51.8%) were overweight, and 31 (37.3%) were obese. Compared with normal-weight patients, mean circumference reduction rates were significantly lower in overweight (P=0.005) and obese patients (P=0.02), but quantitative BMI was not correlated with circumference reduction rate (P=0.96). However, obese patients had a significantly greater reduction in infection episodes than normal-weight patients (P=0.03). In addition, greater BMI predicted greater reduction in infection episodes after VLNT (P=0.02). Conclusions VLNT is an effective surgical treatment, especially for lymphedema patients with higher preoperative BMIs. The results of our study suggest that this procedure considerably decreases the number of postoperative infection episodes per year in obese patients, even though preoperative BMI does not influence circumference reduction rate.
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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
| | - Antonio J Forte
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Maria T Huayllani
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Daniel Boczar
- Division of Plastic Surgery, and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, USA
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Samyd S Bustos
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Atenas Bustamante
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung
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18
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Manrique OJ, Bustos SS, Kapoor T, Lin J, Ciudad P, Forte AJ, Del Corral G, Mani M, Maruccia M, Terzic A. Gastroepiploic vascularized lymph node transfer for the treatment of extremity lymphedema: comparison between middle and distal inset. Gland Surg 2020; 9:528-538. [PMID: 32420288 PMCID: PMC7225493 DOI: 10.21037/gs.2020.02.10] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Middle and distal insets of gastroepiploic vascularized lymph node transfer (GE-VLNT) for extremity lymphedema have been described. However, there has been no prior comparison of surgical or patient-reported outcomes between these techniques. We analyzed the outcomes between both insets in patients with extremity lymphedema. METHODS Retrospective review of patients with extremity-lymphedema who underwent GE-VLNT. Two groups were analyzed: middle and distal recipient inset. We analyzed 6-month surgical and patient-reported outcomes using the Lymphedema Life Impact Scale-v2 (LLISv2) and scar satisfaction utilizing the Patient Scar Assessment Questionnaire (PSAQ). RESULTS Between 2017 and 2019, 26 patients with stage II unilateral extremity lymphedema underwent laparoscopically-harvested GE-VLNT (13 distal and 13 middle inset). There were no differences in patient demographics between groups. Mean hospital stay for patients with upper extremity lymphedema was 1.3 vs. 4.0 days (P<0.05), and for lower extremity lymphedema was 1.0 vs. 4.5 days (P<0.05), middle vs. distal inset, respectively. Mean return to daily activities for patients with upper extremity lymphedema was 13.4 vs. 33.4 days (P<0.05), and for lower extremity lymphedema was 16.0 vs. 29.5 days (P<0.05), middle vs. distal inset, respectively. Both middle and distal inset showed significant mean excess volume reduction at 6 months postoperatively for both upper and lower extremity lymphedema (upper extremity: middle inset 23.3%, distal inset: 22.0%; lower extremity: middle inset 23.3% and distal inset 13.3%). LLISv2 scores showed improved functional outcomes postoperatively in both upper and lower extremity lymphedema with both insets. Scar satisfaction with appearance and symptoms was higher with middle inset (P<0.05). CONCLUSIONS GE-VLNT is an effective surgical treatment for extremity lymphedema. The middle placement showed shorter hospital stay, early return to work and higher patient satisfaction.
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Affiliation(s)
- Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samyd Said Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Jason Lin
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Antonio J. Forte
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Plastic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gabriel Del Corral
- MedStar Plastic and Reconstructive Surgery, Georgetown University Hospital, Washington D.C., USA
| | - Maria Mani
- Department of Plastic Surgery, Uppsala Universitet, Uppsala, Sweden
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Andre Terzic
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
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19
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Ciudad P, Manrique OJ, Bustos SS, Vargas MI, Reynaga C, Agko M, Huang TCT, Benites EF, Mayer HF, Forte AJ. Combined microvascular breast and lymphatic reconstruction with deep inferior epigastric perforator flap and gastroepiploic vascularized lymph node transfer for postmastectomy lymphedema patients. Gland Surg 2020; 9:512-520. [PMID: 32420286 PMCID: PMC7225469 DOI: 10.21037/gs.2020.01.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/12/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The combination of microvascular breast reconstruction (MBR) and vascularized lymph node transfer (VLNT) in a single-stage procedure is a surgical option for women who desire breast reconstruction and postmastectomy lymphedema surgery. In this study, we present a series of patients who underwent simultaneous lymphatic and MBR with the gastroepiploic VLNT (GE-VLNT) and the deep inferior epigastric perforator (DIEP) flap respectively. METHODS Between 2018 and 2019, all consecutive patients diagnosed with lymphedema stage IIb-III International Society of Lymphology who opted to pursue simultaneous MBR with DIEP flap and GE-VLNT were included in this study. Patient demographics, comorbidities, prior radiation therapy, operative characteristics, surgical outcomes and complications were collected and analyzed. RESULTS Six patients underwent simultaneous unilateral MBR with DIEP flap and GE-VLNT. The mean age was 48±10.5 years and mean body mass index was 28.2±4.5 kg/m2. The flap survival rate was 100%. One patient required re-exploration due to venous congestion of the lymph node flap but was successfully salvaged. There was no donor site morbidity at the donor or recipient site for the DIEP flap were seen. The mean circumference reduction rate was 30.0%±5.1% (P<0.001). One patient stage III underwent additional liposuction at 12 months postoperative to improve final results. CONCLUSIONS The combined use of DIEP flap and GE-VLNT flaps in a single-stage procedure is a safe and reliable surgical option for patients with postmastectomy lymphedema who desire and are suitable for autologous microvascular breast and lymphatic reconstruction.
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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, Ciruesthetic Clinic, Lima, Peru
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samyd S. Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
- Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria I. Vargas
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Tony C. T. Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Horacio F. Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
| | - Antonio J. Forte
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, FL, USA
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20
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Comprehensive Overview of Available Donor Sites for Vascularized Lymph Node Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2675. [PMID: 32537339 PMCID: PMC7253262 DOI: 10.1097/gox.0000000000002675] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 11/26/2022]
Abstract
The field of lymphedema surgery has grown tremendously in recent years. In particular, the diversity of available donor sites for vascularized lymph node transfer has increased, and new donor sites are emerging. Researchers have explored a number of different donor sites, and their reports have demonstrated promising results with each site. Unfortunately, there are limited studies providing a comprehensive analysis of the available donor sites focusing on both the technical aspects of the harvest, including complications and donor site morbidity, and the efficacy and outcomes following transfer. The present review aims to present a comprehensive analysis of the available donor sites for vascularized lymph node transfer and a summary of the experience from a single center of excellence.
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21
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Evolution in Surgical Management of Breast Cancer-related Lymphedema: The MD Anderson Cancer Center Experience. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2674. [PMID: 32537338 PMCID: PMC7253265 DOI: 10.1097/gox.0000000000002674] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/18/2019] [Indexed: 11/28/2022]
Abstract
Lymphedema is a lifelong, debilitating condition that plagues a large portion of patients who have undergone multimodality therapy for breast cancer. With the increasing experience in supermicrosurgical treatment of lymphedema, reconstructive surgeons have made a tremendous impact in improving the quality of life of patients suffering from breast cancer related lymphedema.
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22
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Ciudad P, Manrique OJ, Bustos SS, Coca JJP, Chang C, Shih P, Nicoli F, Lo Torto F, Agko M, Huang TC, Maruccia M, Chen H. Comparisons in long‐term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery 2020; 40:130-136. [DOI: 10.1002/micr.30508] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 08/08/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Samyd S. Bustos
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - John J. P. Coca
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
| | - Chang‐Cheng Chang
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Pin‐Keng Shih
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive SurgeryUniversity of Rome “Tor Vergata” Rome Italy
| | - Federico Lo Torto
- Sapienza Università di Roma, Policlinico Umberto I, Department of Surgery “P. Valdoni”Unit of Plastic Reconstructive and Aesthetic Surgery Rome Italy
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Tony C.‐T. Huang
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
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23
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Maruccia M, Pezzolla A, Nacchiero E, Dicillo P, Macchia L, Fiore P, Giudice G, Elia R. Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema. Microsurgery 2019; 39:679-687. [DOI: 10.1002/micr.30511] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/20/2019] [Accepted: 08/23/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Angela Pezzolla
- Division of Videolaparoscopic Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Eleonora Nacchiero
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Patrizia Dicillo
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Laura Macchia
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Piero Fiore
- Department of Basic Medical Sciences, Neuroscience and Sensory OrgansUniversity of Bari "Aldo Moro" Bari Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Aldo Moro Bari Italy
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24
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Fan KL, Black CK, Song DH, Del Corral GA. The "String of Pearls" technique for increased surface area and lymphedematous fluid drainage in right gastroepiploic-vascularized lymph node transfer: A report of two cases. Microsurgery 2019; 39:548-552. [PMID: 31225685 DOI: 10.1002/micr.30484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 11/09/2022]
Abstract
We present our "String of Pearls" technique for upper and lower extremity lymphedema based off the right gastroepiploic artery. The entire laprascopically harvested omentum is placed through a longitudinal incision at the lymphedematous area, and anastomosed proximally, with additional distal venous outflow. This approach preserves the native lymphaticovenous architecture, distributes free lymphatic tissue along the axis of the extremity, and allows for scar release. The additional vein serves to restore bidirectional physiologic drainage inherent in the omentum and providing further lymphaticovenous drainage. We present two cases of upper and lower extremity lymphedema as a result of malignancy treated using this method. The first case was a result of breast cancer in a 55-year-old female with orthotopically placed omentum, and the second case a result of malignant nodular fasciitis in the distal lower extremity in a 56-year-old female with distally placed omentum. No complications occurred. At 3 months follow up, there is a 25% and 28% reduction in lower and upper extremity volume, respectively, with no recurrent cellulitis episodes. The safety and feasibility of placement of the entire omentum longitudinally with additional venous anastomosis are apparent. However, long-term studies are required.
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Affiliation(s)
- Kenneth L Fan
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - Cara K Black
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - David H Song
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
| | - Gabriel A Del Corral
- MedStar Plastic and Reconstructive Surgery, MedStar Health, Washington, District of Columbia
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25
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Ciudad P, Sabbagh MD, Agko M, Huang TCT, Manrique OJ, L CR, Reynaga C, Delgado R, Maruccia M, Chen HC. Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review. Indian J Plast Surg 2019; 52:81-92. [PMID: 31456616 PMCID: PMC6664851 DOI: 10.1055/s-0039-1688537] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Tony C T Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Carmen Román L
- Department of Physical and Rehabilitation Medicine, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Cesar Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Ricardo Delgado
- Department of Plastic and Reconstructive Surgery, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Michele Maruccia
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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26
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Markkula SP, Leung N, Allen VB, Furniss D. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Cochrane Database Syst Rev 2019; 2:CD011433. [PMID: 30779124 PMCID: PMC6379660 DOI: 10.1002/14651858.cd011433.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast cancer is the most common type of cancer amongst women worldwide, and one distressing complication of breast cancer treatment is breast and upper-limb lymphoedema. There is uncertainty regarding the effectiveness of surgical interventions in both the prevention and management of lymphoedema affecting the arm after breast cancer treatment. OBJECTIVES 1. To assess and compare the efficacy of surgical interventions for the prevention of the development of lymphoedema (LE) in the arm after breast cancer treatment.2. To assess and compare the efficacy of surgical interventions for the treatment of established LE in the arm after breast cancer treatment. SEARCH METHODS We searched the Cochrane Breast Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the WHO International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for all prospectively registered and ongoing trials on 2 November 2017. Reference lists of included studies were also handsearched by three review authors for additional eligible trials. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing a surgical intervention for the prevention or treatment of lymphoedema of the arm after breast cancer treatment to either standard intervention, placebo intervention, or another surgical intervention were included. Patients of both sexes and all ages who have had treatment for their breast cancer were considered. No limits were applied to language or study location. Three authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS Three authors independently extracted data for each included study using a pre-designed data extraction pro forma and used Cochrane's 'risk of bias' tool for assessing risk of bias. Dichotomous variables were analysed using the Mantel-Haenszel method to estimate risk ratios (RRs). Differences in continuous variables were expressed as mean differences (MDs). GRADE was used to assess the certainty of the evidence provided by the included studies. MAIN RESULTS Two studies involving 95 participants examined surgical interventions for preventing breast cancer-related lymphoedema. Both studies evaluated the efficacy of the lymphaticovenular anastomosis technique as part of a preventative management protocol. Both studies were deemed to be at unclear risk of bias overall. Statistical variation between the studies was low, which increases the reliability of the evidence. However, the two studies were conducted in the same centre. Lymphaticovenular anastomosis appears to result in a reduction in the incidence of lymphoedema compared to nonoperative management with a risk ratio of 0.20 (95% CI 0.06 to 0.63, P = 0.006; 95 participants; low-certainty evidence). The RCTs did not evaluate any of the secondary outcomes.One study involving 36 participants evaluated the effectiveness of vascularised lymph node transfer for treating breast cancer-related lymphoedema. The trial was deemed to be at unclear risk of bias. For participants suffering from stage 2 lymphoedema, the evidence suggested reductions in limb volume (MD -39.00%, 95% CI -47.37% to -30.63%, very low-certainty evidence), pain scores (MD -4.16, 95% CI -5.17 to -3.15, very low-certainty evidence), heaviness sensation (MD -4.27, 95% CI -5.74 to -2.80, very low-certainty evidence), mean number of infections/year (MD -1.22, 95% CI -2.00 to -0.44, very low-certainty evidence), and an improvement in overall function scores (MD -3.77, 95% CI -4.89 to -2.65, very low-certainty evidence) for those who had undergone vascularised lymph node transfer compared to those who had undergone no treatment. AUTHORS' CONCLUSIONS There is low-certainty evidence that lymphaticovenular anastomosis is effective in preventing the development of lymphoedema after breast cancer treatment based on the findings from two studies. One study providing very low-certainty evidence found that vascularised lymph node transfer is an efficacious option in the treatment of established stage 2 lymphoedema related to breast cancer. Important secondary outcomes in this review were rarely reported in the included studies. More high-quality RCTs are required to further elucidate the effectiveness of surgical interventions in the prevention and treatment of lymphoedema after breast cancer treatment. At the time of this review, no ongoing trials on this topic were identified.
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Affiliation(s)
- Silja P Markkula
- Helsinki University HospitalDepartment of Plastic SurgeryPL 266HelsinkiFinlandFIN‐00029 HUS
| | | | - Victoria B Allen
- St. Thomas' HospitalDepartment of InfectionWestminster Bridge RoadLondonUKSE1 7EH
| | - Dominic Furniss
- NDORMS, Oxford UniversityBotnar Research CentreWindmill RoadOxfordOxfordshireUKOX3 7HF
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Anatomical Basis of the Gastroepiploic Vascularized Lymph Node Transfer: A Radiographic Evaluation Using Computed Tomographic Angiography. Plast Reconstr Surg 2019; 142:1046-1052. [PMID: 30020230 DOI: 10.1097/prs.0000000000004772] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The omentum, nourished by the gastroepiploic vessels, has gained popularity as an option for vascularized lymph node transfer. The anatomy of the gastroepiploic vessels, omentum, and lymph nodes has not been investigated. The purpose of this article is to describe the right gastroepiploic artery and related structures by using computed tomographic angiography. METHODS A retrospective analysis was conducted on 34 patients who underwent computed tomographic angiography. Statistical models were applied to identify right gastroepiploic artery and lymph node anatomical characteristics. RESULTS The right gastroepiploic artery was identified in 33 of 34 patients. It was found to have a diameter of 2.49 ± 0.66 mm at its origin. The gastroduodenal artery length before right gastroepiploic artery takeoff was 3.09 ± 1.31 cm. Twenty-five patients had lymph nodes in the right gastroepiploic artery lymphosome. There were 2.7 ± 2.12 lymph nodes identified per patient. The distance from the right gastroepiploic artery origin to the most proximal lymph node was 3.99 ± 2.21 cm. The distance from the gastroepiploic artery origin to the third lymph node was 9.12 ± 5.06 cm. Each lymph node was within 7.00 ± 6.2 mm of the right gastroepiploic artery. CONCLUSIONS When using the right gastroepiploic artery donor site for vascularized lymph node transfer, the plastic surgeon should anticipate using a pedicle length of 4 cm, a total flap length of 9 cm, and 3 cm of surrounding tissue to obtain at least three lymph nodes for transfer. Computed tomographic angiography is an effective imaging modality that can be used for patient-specific surgical navigation before vascularized lymph node transfer.
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Ciudad P, Manrique OJ, Adabi K, Huang TCT, Agko M, Trignano E, Chang WL, Chen TW, Salgado CJ, Chen HC. Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema. J Surg Oncol 2019; 119:439-448. [DOI: 10.1002/jso.25360] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/19/2018] [Accepted: 12/16/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Burn Surgery; Arzobispo Loayza National Hospital; Lima Peru
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | | | - Mouchammed Agko
- Department of Plastic Surgery; Medical College of Georgia; Augusta University; Augusta Georgia
| | - Emilio Trignano
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
| | - Tsung-Wei Chen
- Department of Pathology; China Medical University; Taichung Taiwan
| | - Christopher J. Salgado
- Division of Plastic, Reconstructive and Aesthetic Surgery; University of Miami Miller School of Medicine; Miami Florida
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University; Taichung Taiwan
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Ishikawa K, Maeda T, Funayama E, Hayashi T, Murao N, Osawa M, Furukawa H, Oyama A, Yamamoto Y. Feasibility of pedicled vascularized inguinal lymph node transfer in a mouse model: A preliminary study. Microsurgery 2018; 39:247-254. [PMID: 30508286 DOI: 10.1002/micr.30394] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/31/2018] [Accepted: 10/05/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice. METHODS Twenty-five mice were used in the study. An inguinal lymph node-bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining. RESULTS In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 ± 0.24 mm2 ) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 ± 1.17 mm2 ); the cell population was too dense to allow identification of follicles. CONCLUSIONS We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.
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Affiliation(s)
- Kosuke Ishikawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Aichi Medical University, Nagakute, Japan
| | - Akihiko Oyama
- Department of Plastic and Reconstructive Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Khan AA, Hernan I, Adamthwaite JA, Ramsey KWD. Feasibility study of combined dynamic imaging and lymphaticovenous anastomosis surgery for breast cancer-related lymphoedema. Br J Surg 2018; 106:100-110. [PMID: 30295931 DOI: 10.1002/bjs.10983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/10/2018] [Accepted: 07/22/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breast cancer-related lymphoedema (BCRL) presents a significant healthcare burden and adversely affects quality of life of breast cancer survivors. A prospective feasibility study was performed on lymphaticovenous anastomosis (LVA) for the treatment of BCRL. METHODS Patients with BCRL underwent near-infrared spectroscopy with indocyanine green lymphatic mapping to identify suitable lymphatic channels for LVA. End-to-end anastomoses to subdermal venules were performed and patients recommenced compression garment therapy (CGT) after surgery. Volumetric assessment of the affected limb was performed at regular intervals using infrared perometry to calculate the excess volume reduction. RESULTS Over a 24-month interval, 27 patients with BCRL underwent LVA. The mean duration of lymphoedema was 3·5 (range 0·5-18) years, and the mean number of LVAs performed was 3 (range 2-5). Twenty-four of the 27 patients completed 12-month follow-up. Patients exhibited three patterns of volumetric response following LVA: sustained response (16 patients), transient response (5) or no response (6). Sustained responders showed an excess volume reduction of -33·2 per cent at 12 months, and this correlated positively with the number of LVAs performed (r = -0·56, P = 0·034). Overall, ten patients were able to downgrade CGT after surgery, and two patients were CGT-free at 12 months. CONCLUSION LVA resulted in a sustained volume reduction in selected patients and may offset the burden of CGT. Further work is required to identify biomarkers that predict a favourable response to LVA surgery.
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Affiliation(s)
- A A Khan
- Institute of Cancer Research, London, UK
| | - I Hernan
- Department of Plastic and Reconstructive Surgery, Royal Marsden Hospital, London, UK
| | - J A Adamthwaite
- Department of Plastic and Reconstructive Surgery, Royal Marsden Hospital, London, UK
| | - K W D Ramsey
- Department of Plastic and Reconstructive Surgery, Royal Marsden Hospital, London, UK
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Mesoappendix as potential donor site for vascularized lymph node transfer: anatomic study. J Surg Res 2018; 230:143-147. [PMID: 30100031 DOI: 10.1016/j.jss.2018.03.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 02/20/2018] [Accepted: 03/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The standard of care for treatment of lymphedema is manual lymphatic drainage and compression therapy, which is time intensive and requires a life-long commitment. Autologous lymph node transfer is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the lymphedematous region to assist with lymph fluid clearance. An ideal donor lymph node site minimizes the risk of iatrogenic lymphedema and other donor site morbidity. To address this, we have used jejunal mesentery lymph nodes and omental flaps and hypothesize that the mesoappendix, as a "spare part," may be an ideal autologous lymph node transfer donor site. METHODS In this Institutional Review Board-approved study, 25 mesoappendix pathology specimens resected for benign disease underwent gross pathologic examination for the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length. RESULTS A single lymph node was present in two of 25 specimens (8%). Mean arterial and vein calibers at the point of ligation were 0.87 ± 0.44 mm and 0.86 ± 0.48 mm (range 0.30-2.2 mm and 0.25-2.2 mm), respectively. Mean arterial and vein length was 1.70 ± 1.06 cm and 1.84 ± 1.09 cm (range 0.8-4.5 cm for each), respectively. CONCLUSIONS The mesoappendix rarely contains a lymph node. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber preferred for microsurgical anastomosis. If transplantation of a vascularized lymph node for the treatment of lymphedema is desired, the mesoappendix is inconsistent in providing adequate lymph nodes.
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Chang EI, Masià J, Smith ML. Combining Autologous Breast Reconstruction and Vascularized Lymph Node Transfer. Semin Plast Surg 2018; 32:36-41. [PMID: 29636652 DOI: 10.1055/s-0038-1632402] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Breast cancer patients are at risk for developing postmastectomy lymphedema syndrome of the ipsilateral upper extremity following treatment for breast cancer in the setting of an axillary dissection, postoperative radiation, and chemotherapy. For patients suffering from lymphedema who are also seeking breast reconstruction, combining an autologous abdominal free flap with a vascularized inguinal lymph node transfer provides patients the opportunity to have an aesthetic breast reconstruction as well as the potential to improve their lymphedema in a single operation. The present article aims to provide a description of the salient features of this approach including the preoperative preparation, the surgical technique, the postoperative management and complications, and a summary of the outcomes.
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Affiliation(s)
- Edward I Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaume Masià
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Mark L Smith
- Division of Plastic Surgery, Northwell Health System, Lake Success, New York
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Laparoscopic Gastroepiploic Lymphovascular Pedicle Harvesting for the Treatment of Extremity Lymphedema: A Novel Technique. Surg Laparosc Endosc Percutan Tech 2018; 27:e40-e43. [PMID: 28582379 DOI: 10.1097/sle.0000000000000412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Vascularized lymph node transfers have multiple donor sites with risk of iatrogenic lymphedema. We sought to describe in detail a surgical technique that is safe, reproducible, and efficient in harvesting gastroepiploic vascularized lymph nodes using real-time indocyanine green (ICG) fluorescent imaging. Photographs and video were acquired from a case to depict a step-by-step approach. ICG was endoscopically injected into the submucosa of the greater curvature of the stomach at the outset of the procedure. A laparoscopic harvest of the gastroepiploic vascular pedicle and lymph nodes ensued with the assistance of fluorescent imaging. Laparoscopic gastroepiploic lymph node harvesting aided by real-time ICG fluorescent mapping technique is safe, feasible, and effective at gathering vascularized lymphatic tissue for successful lymph node transfer in patients with severe lymphedema.
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Maruccia M, Pezzolla A, Elia R, Vestita M, Nacchiero E, Giudice G. LETTER TO THE EDITOR. J Surg Oncol 2018; 117:1344-1345. [DOI: 10.1002/jso.24958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Michele Maruccia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Angela Pezzolla
- Section of Videolaparoscopic Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Rossella Elia
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Michelangelo Vestita
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Eleonora Nacchiero
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
| | - Giuseppe Giudice
- Section of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation; University of Bari; Bari Italy
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Ciudad P, Mouchammed A, Manrique OJ, Chang WL, Huang TC, Chen HC. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2018; 117:1346-1347. [PMID: 29357118 DOI: 10.1002/jso.24957] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 12/03/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Agko Mouchammed
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Tony C.T. Huang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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36
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Agko M, Ciudad P, Chen HC. Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study. J Surg Oncol 2018; 117:1148-1156. [PMID: 29355987 DOI: 10.1002/jso.24969] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 12/08/2017] [Indexed: 01/03/2023]
Affiliation(s)
- Mouchammed Agko
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
| | - Pedro Ciudad
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery; China Medical University Hospital; Taichung Taiwan
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37
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Agko M, Ciudad P, Chen HC. Histo-anatomical basis of the gastroepiploic vascularized lymph node flap: The overlooked "micro" lymph nodes. J Plast Reconstr Aesthet Surg 2017; 71:118-120. [PMID: 28851614 DOI: 10.1016/j.bjps.2017.08.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 05/25/2017] [Accepted: 08/06/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Mouchammed Agko
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan.
| | - Pedro Ciudad
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan; Department of Biological Science and Technology, China Medical University, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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Akita S, Yamaji Y, Tokumoto H, Adachi N, Sasahara Y, Kubota Y, Kuriyama M, Mitsukawa N. Abdominoplasty with Lymphatic Microsurgery for Patients with Secondary Lower Extremity Lymphedema. Plast Reconstr Surg 2017; 140:719e-723e. [PMID: 28746237 DOI: 10.1097/prs.0000000000003755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients with secondary lower extremity lymphedema often develop suprapubic lymphedema. The authors developed a novel surgical method of shaping the lower abdomen and debulking suprapubic lymphedema with simultaneous reconstruction of lymphatic flow in case of lower extremity lymphedema. METHODS A fleur-de-lis skin incision pattern was performed for horizontal and vertical abdominal skin and fat resection. A caudally based isosceles triangular flap was created on the central suprapubic region to reduce wound tension at the intersection of the horizontal and vertical incisions. After resection and debulking of the suprapubic region, a lymphaticovenular anastomosis between the efferent lymphatic vessel of the groin node and the superficial inferior epigastric vein was created or vascularized lymph node transfer to the groin region was performed to restore lymphatic flow. Lymphaticovenular anastomosis and lymph node transfer were also performed at the lower extremities to improve lower extremity lymphedema. Perioperative change in limb volume was evaluated using the lower extremity lymphedema index, and lymphatic function was evaluated by lymphoscintigraphy. RESULTS Simultaneous abdominoplasty and reconstructive lymphatic microsurgery were performed in 11 patients. The lower extremity lymphedema index improved perioperatively, with a significant difference (p < 0.01). In eight patients who underwent lymphoscintigraphy before and after surgery, the lymphatic function was found to have not deteriorated in any limb. CONCLUSIONS When simultaneous lymphatic microsurgical procedures and careful observation for complications were performed, abdominoplasty resulted in good outcomes in patients with lower extremity lymphedema and suprapubic lymphedema without worsening of lymphedema. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
- Shinsuke Akita
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Yoshihisa Yamaji
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Hideki Tokumoto
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Naoki Adachi
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Yoshitaro Sasahara
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Yoshitaka Kubota
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Motone Kuriyama
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
| | - Nobuyuki Mitsukawa
- Chiba, Ibaragi-cho, and Nankoku, Japan.,From the Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine; the Division of Plastic and Reconstructive Surgery, Chiba Cancer Center; the Department of Surgery, Mito Medical Center; and the Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital
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Ciudad P, Agko M, Perez Coca JJ, Manrique OJ, Chang WL, Nicoli F, Chen SH, Chen HC. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol 2017; 116:671-682. [PMID: 28695707 DOI: 10.1002/jso.24730] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/21/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
- Peru Plastic and Reconstructive Surgery Research Institute; Lima Peru
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - John Jaime Perez Coca
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang-Gung University; Linkou Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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Ciudad P, Manrique OJ, Agko M, Liu EW, Chang WL, Sze-Wei Yeo M, Huang TCT, Chilgar RM, Chen HC. Ileocecal vascularized lymph node transfer for the treatment of extremity lymphedema: A case report. Microsurgery 2017; 39:81-84. [PMID: 28543381 DOI: 10.1002/micr.30186] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/22/2017] [Accepted: 04/26/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - En-Wei Liu
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | | | - Tony Chieh-Ting Huang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Ram M. Chilgar
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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41
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Ciudad P, Manrique OJ, Date S, Agko M, Perez Coca JJ, Chang WL, Lo Torto F, Nicoli F, Maruccia M, López Mendoza J, Chen HC. Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema. Microsurgery 2017; 37:771-779. [PMID: 28334445 DOI: 10.1002/micr.30168] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - John Jaime Perez Coca
- Institute of Biotechnology, National Chung Hsing University; Taichung Taiwan, Republic of China
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michelle Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Javier López Mendoza
- Hand and Microsurgery Clinic, Hospital Ángeles del Pedregal Ciudad de México; México
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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