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Chao S, Kuan C, Lin Y, Tai H, Cheng N. Lymphovenous Bypass as an Alternative Strategy for Managing Phleboedema and Venous Leg Ulcers: Preliminary Results. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6064. [PMID: 39148508 PMCID: PMC11326461 DOI: 10.1097/gox.0000000000006064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 06/21/2024] [Indexed: 08/17/2024]
Abstract
Background Chronic venous leg ulcers (VLUs) are a common manifestation of chronic venous insufficiency, accounting for up to 70% of all chronic leg ulcers. Patients sustained refractory ulcers and persistent phleboedema even with a combination of different treatment methods. Lymphovenous bypass (LVB) has shown promising results in patients with lymphedema. We hypothesize that LVB could potentially alleviate VLUs and phleboedema, given their symptom similarities with lymphedema. Methods From May 2021 to June 2023, we prospectively deployed LVB in patients with nonhealing stasis ulcers after 4-week traditional care, or in those with persistent phleboedema despite prior surgery for vein etiologies. Demographics, healing course and recurrence, lymphoscintigraphy, and VLU quality of life (QoL) questionnaires were collected. Results Thirty-one patients were treated with LVB and additional skin grafting as necessary. Their mean age was 62.6 ± 14.7 years, with male predominance (20, 64.5%), and most patients sustained clinical, etiologic, anatomic, pathophysiologic classification C6 (25, 80.6%). Postoperatively, wound healing and phleboedema decongestion were observed mostly within 2 months. The VLU QoL questionnaire (39.3% response rate) showed improvement in QoL in activities, and psychological and symptom distress aspects. Conclusions Using LVB for chronic venous insufficiency showed an increase in the success rate of ulcer healing and decompression of the swollen limbs with durable results. Patient-reported outcome measures disclosed the potential benefits of LVB. Large-scale randomized controlled trials and pathophysiological studies are warranted to elucidate its efficacy.
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Affiliation(s)
- Sungchuan Chao
- From the Department of Traumatology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chenhisang Kuan
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yingsheng Lin
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Yunlin, Taiwan
| | - Haochih Tai
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Naichen Cheng
- Department of Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Aguilar-Guadarrama AB, Díaz-Román MA, Osorio-García M, Déciga-Campos M, Rios MY. Chemical Constituents from Agave applanata and Its Antihyperglycemic, Anti-inflammatory, and Antimicrobial Activities Associated with Its Tissue Repair Capability. PLANTA MEDICA 2024; 90:397-410. [PMID: 38365219 DOI: 10.1055/a-2270-5527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Agave applanata is a Mexican agave whose fresh leaves are employed to prepare an ethanol tonic used to relieve diabetes. It is also applied to skin to relieve varicose and diabetic foot ulcers, including wounds, inflammation, and infections. In this study, the chemical composition of this ethanol tonic is established and its association with antihyperglycemic, anti-inflammatory, antimicrobial, and wound healing activities is discussed. The fresh leaves of A. applanata were extracted with ethanol : H2O (85 : 15). A fraction of this extract was lyophilized, and the remainder was partitioned into CH2Cl2, n-BuOH, and water. CH2Cl2 and n-BuOH fractions were subjected to a successive open column chromatography process. The structure of the isolated compounds was established using nuclear magnetic resonance and mass spectrometry spectra. The antihyperglycemic activity was evaluated through in vivo sucrose and glucose tolerance experiments, as well as ex vivo intestinal absorption and hepatic production of glucose. Wound healing and edema inhibition were assayed in mice. The minimum inhibitory concentrations (MICs) of the hydroalcoholic extract, its fractions, and pure compounds were determined through agar microdilution against the most isolated pathogens from diabetic foot ulcers. Fatty acids, β-sitosterol, stigmasterol, hecogenin (1: ), N-oleyl-D-glucosamine, β-daucosterol, sucrose, myo-inositol, and hecogenin-3-O-α-L-rhamnopyranosyl-(1 → 3)-β-D-xylopyranosyl-(1 → 2)-[β-D-xylopyranosyl-(1 → 3)-β-D-glucopyranosyl-(1 → 3)]-β-D-glucopyranosyl-(1 → 4)-β-D-galactopyranoside (2: ) were characterized. This research provides evidence for the pharmacological importance of A. applanata in maintaining normoglycemia, showing anti-inflammatory activity and antimicrobial effects against the microorganisms frequently found in diabetic foot ulcers. This plant plays an important role in wound healing and accelerated tissue reparation.
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Affiliation(s)
| | - Mónica Aideé Díaz-Román
- Centro de Investigaciones Químicas-IICBA, Universidad Autónoma del Estado de Morelos, Morelos, México
| | - Maribel Osorio-García
- Centro de Investigaciones Químicas-IICBA, Universidad Autónoma del Estado de Morelos, Morelos, México
| | - Myrna Déciga-Campos
- Escuela Superior de Medicina, Instituto Politécnico Nacional, Ciudad de México, México
| | - María Yolanda Rios
- Centro de Investigaciones Químicas-IICBA, Universidad Autónoma del Estado de Morelos, Morelos, México
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Lippi L, Ferrillo M, Losco L, Folli A, Marcasciano M, Curci C, Moalli S, Ammendolia A, de Sire A, Invernizzi M. Aesthetic Rehabilitation Medicine: Enhancing Wellbeing beyond Functional Recovery. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:603. [PMID: 38674249 PMCID: PMC11052208 DOI: 10.3390/medicina60040603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024]
Abstract
Although rehabilitation medicine emphasizes a holistic health approach, there is still a large gap of knowledge about potential interventions aimed at improving overall wellbeing through cosmetic interventions. Therefore, this narrative review investigates the role of different rehabilitative techniques in enhancing aesthetics, quality of life, and psychosocial wellbeing for patients with disabilities. The study follows the SANRA framework quality criteria for a narrative review. Literature searches across PubMed/Medline, Web of Science, and Scopus identified articles focusing on rehabilitation strategies within the aesthetic rehabilitation domain. The review identified evidence supporting injection procedures, such as Botulinum Toxin, Platelet-Rich Plasma, Hyaluronic Acid, Ozone, and Carboxytherapy, and assessing their applications in several disabling disorders. Additionally, physical therapies like Extracorporeal Shock Wave Therapy, Laser Therapy, Microcurrent Therapy, Tecar Therapy, and physical exercises were explored for their impact on cutaneous microcirculation, cellulite treatment, wound healing, and scar appearance improvement. Lastly, the manuscript underlines the role of manual therapy techniques in addressing both physical discomfort and aesthetic concerns, discussing their effectiveness in adipose tissue therapy, scar tissue mobilization, and regional fat thickness reduction. Taken together, this review emphasizes the role of a multidisciplinary approach, aiming to provide valuable insights into potential benefits for both functional and aesthetic outcomes.
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Affiliation(s)
- Lorenzo Lippi
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.F.); (S.M.); (M.I.)
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Martina Ferrillo
- Department of Health Sciences, School of Dentistry, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy;
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, Via Salvador Allende, 43, 84081 Baronissi, Italy;
| | - Arianna Folli
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.F.); (S.M.); (M.I.)
| | - Marco Marcasciano
- Plastic Surgery, Experimental and Clinical Medicine Department, Division of Plastic and Reconstructive Surgery, “Magna Graecia” University of Catanzaro, 88100 Catanzaro, Italy;
| | - Claudio Curci
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, ASST Carlo Poma, 46100 Mantova, Italy
| | - Stefano Moalli
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.F.); (S.M.); (M.I.)
| | - Antonio Ammendolia
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy;
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Alessandro de Sire
- Physical and Rehabilitative Medicine, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy;
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Marco Invernizzi
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.F.); (S.M.); (M.I.)
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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Marra C, Pentangelo P, Losco L, Ceccaroni A, Barbato A, Alfano C. Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy. J Clin Med 2024; 13:1407. [PMID: 38592225 PMCID: PMC10931990 DOI: 10.3390/jcm13051407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/10/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.
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Affiliation(s)
- Caterina Marra
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Paola Pentangelo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Alessandra Ceccaroni
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Alfonso Barbato
- Plastic Surgery Unit, Azienda Ospedaliera Universitaria OO.RR. San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, SA, Italy
| | - Carmine Alfano
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
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Bolletta A, Losco L, Cigna E. Editorial for the Special Issue "Vasorum Lymphaticorum: From the Discovery of the Lymphatic System to the New Perspectives in Microsurgical Reconstruction and Patient Rehabilitation". MEDICINA (KAUNAS, LITHUANIA) 2024; 60:307. [PMID: 38399594 PMCID: PMC10890691 DOI: 10.3390/medicina60020307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Lymphedema is a complex clinical condition that appears as a result of the failure of the lymphatic system function, and it is characterized by edema, fibrosis, and adipose deposition [...].
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Affiliation(s)
- Alberto Bolletta
- Plastic Surgery and Microsurgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Salerno, Italy
| | - Emanuele Cigna
- Plastic Surgery and Microsurgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
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Surgical Treatment and Rehabilitation Strategies for Upper and Lower Extremity Lymphedema: A Comprehensive Review. Medicina (B Aires) 2022; 58:medicina58070954. [PMID: 35888673 PMCID: PMC9324426 DOI: 10.3390/medicina58070954] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/07/2023] Open
Abstract
Lymphedema is a chronic disabling condition affecting a growing number of patients worldwide. Although lymphedema is not life-threatening, several reports underlined detrimental consequences in terms of distress, pain, functional impairment, and infections with a relevant decrease in quality of life. Currently, there is no cure, and the therapeutic management of this condition aims at slowing down the disease progression and preventing secondary complications. Early diagnosis is paramount to enhance the effects of rehabilitation or surgical treatments. On the other hand, a multidisciplinary treatment should be truly integrated, the combination of microsurgical and reductive procedures should be considered a valid strategy to manage extremity lymphedema, and rehabilitation should be considered the cornerstone of the multidisciplinary treatment not only for patients not suitable for surgical interventions but also before and after surgical procedures. Therefore, a specialized management of Plastic Reconstructive Surgeons and Physical and Rehabilitative Medicine physicians should be mandatory to address patients’ needs and optimize the treatment of this disabling and detrimental condition. Therefore, the aim of this review was to characterize the comprehensive management of lymphedema, providing a broad overview of the potential therapy available in the current literature to optimize the comprehensive management of lymphedema and minimize complications.
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Lymphaticovenous Anastomosis for Treating Secondary Lower Limb Lymphedema in Older Patients-A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11113089. [PMID: 35683479 PMCID: PMC9181524 DOI: 10.3390/jcm11113089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/19/2022] [Accepted: 05/26/2022] [Indexed: 11/16/2022] Open
Abstract
Despite an increased incidence of secondary lower limb lymphedema (LLL) and severity of comorbidities with age, the impact of age on the effectiveness of lymphaticovenous anastomosis (LVA) in the older patients remains unclear. Methods: This retrospective cohort study enrolled older patients (age > 65 years) with secondary unilateral LLL. All patients underwent supermicrosurgical LVA. Demographic data and intraoperative findings including lymphatic vessel (LV) diameter, LV functionality (indocyanine green-enhanced and Flow positivity), and lymphosclerosis classification were recorded. Magnetic resonance volumetry was used for measuring preoperative and postoperative volume changes at 6 months and one year after LVA as primary and secondary endpoints. Results: Thirty-two patients (29 females/3 males) with a median age of 71.0 years [range, 68.0 to 76.3] were enrolled. The median duration of lymphedema was 6.4 [1.0 to 11.7] years. The median LV diameter was 0.7 [0.5 to 0.8] mm. The percentage of ICG-enhanced and Flow-positive LVs were 89.5% and 85.8%, respectively. The total percentage of suitable LVs (s0 and s1) for LVA based on lymphosclerosis classification was 75.9%. There were significant six-month and one-year post-LVA percentage volume reductions compared to pre-LVA volume (both p < 0.001). A significant reduction in cellulitis incidence was also noted after LVA (p < 0.001). No surgical or postoperative complications were found. Conclusion: Relief of secondary LLL was achievable through LVA in older patients who still possessed favorable LV characteristics, including larger LV diameters as well as a high proportion of functional LVs with a low grade of lymphosclerosis.
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Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050631. [PMID: 35630048 PMCID: PMC9143574 DOI: 10.3390/medicina58050631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.
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Clinical Evaluation of the Efficacy and Tolerability of Rigenase ® and Polyhexanide (Fitostimoline ® Plus) vs. Hyaluronic Acid and Silver Sulfadiazine (Connettivina ® Bio Plus) for the Treatment of Acute Skin Wounds: A Randomized Trial. J Clin Med 2022; 11:jcm11092518. [PMID: 35566643 PMCID: PMC9105357 DOI: 10.3390/jcm11092518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/13/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Compare the efficacy and tolerability of Connettivina® Bio Plus (Group A) gauze and cream, and Fitostimoline® Plus (Group B) gauze and cream for the treatment of acute superficial skin lesions. Design: Single-center, parallel, randomized trial. A block randomization method was used. Setting: University of Salerno—AOU San Giovanni di Dio e Ruggi d’Aragona. Participants: Sixty patients were enrolled. All patients fulfilled the study requirements. Intervention: One application of the study drugs every 24 h, and a six-week observation period. Main outcome measures: Efficacy and tolerability of the study drugs. Results: In total, 60 patients (Group A, n = 30; Group B, n = 30) were randomized; mean age was 58.5 ± 15.8 years. All patients were included in the outcome analysis. Total wound healing was achieved in 17 patients undergoing treatment with Connettivina® Bio Plus and 28 patients undergoing treatment with Fitostimoline® Plus. The greater effectiveness of the latter was significant (p = 0.00104). In Group B, a significantly greater degree of effectiveness was observed in reducing the fibrin in the wound bed (p = 0.04746). Complications or unexpected events were not observed. Conclusions: Both Connettivina® Bio Plus and Fitostimoline® Plus are secure and effective for treating acute superficial skin lesions. Fitostimoline® Plus was more effective than Connettivina® Bio Plus in wound healing of acute superficial skin lesions, especially if fibrin had been observed in the wound bed.
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Scaglioni MF, Meroni M, Fritsche E. Soft Tissue Defect Reconstruction and Lymphatic Complications Prevention: The Lymphatic Flow-Through (LyFT) Concept. Medicina (B Aires) 2022; 58:medicina58040509. [PMID: 35454348 PMCID: PMC9024656 DOI: 10.3390/medicina58040509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/28/2022] Open
Abstract
Background and Objectives: When a lymphatic-rich area is severely damaged, either after trauma or a surgical procedure, both soft tissue defect reconstruction and lymphatic drainage restoration are necessary. In this setting, we aim to show the potential of the lymphatic flow-through flap (LyFT) concept, which might be an attractive new solution to reduce postoperative lymphatic complications. Materials and Methods: Between 2018 and 2021, 12 patients presenting a soft tissue defect involving damage to the lymphatic drainage pathway received a lymphatic flow-through flap for volume and lymphatic drainage restoration. Different flaps were employed: 3 pedicled superficial circumflex iliac artery perforator (SCIP) flaps, 2 free SCIP flaps, 3 pedicled deep inferior epigastric perforator (DIEP) flaps, 2 pedicled vertical posteromedial thigh (vPMT) flaps, and 2 pedicled anterolateral thigh (ALT) flaps. A range of 1 to 3 lymphovenous anastomosis (LVA) with flap’s veins was performed (mean 1.9). For a better dead space obliteration, an additional vastus lateralis muscle flap was performed in one case. Indocyanine green (ICG) lymphography was used in all cases to identify the lymphatic pathway, make the preoperative markings, and check the patency of the anastomoses. Results: In all cases, the reconstructive results were satisfactory from both the functional and aesthetic points of view. No secondary surgeries were required, and only one minor complication was encountered: an infected seroma that was managed conservatively. The mean follow-up was 9.9 months (range 6–14 months). Conclusions: Lymphatic flow-through flaps seem to effectively reduce the risk of lymphatic complications after the reconstruction of soft tissue defects with a compromised lymph pathway. This is a versatile solution that might be used in different body regions resorting to different flap types.
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Perforator-based Adipofascial Flaps and ADM: A Novel Combined Approach to Distal Lower Extremity Defects. Plast Reconstr Surg Glob Open 2022; 10:e4131. [PMID: 35198355 PMCID: PMC8856593 DOI: 10.1097/gox.0000000000004131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/14/2021] [Indexed: 11/25/2022]
Abstract
Due to the wide spectrum of lower extremity defect presentation, various reconstructive techniques are available. Classic adipofascial flaps are still a second choice. The authors described a new multistage reconstructive approach with perforator-based pedicled adipofascial flap.
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Pierazzi DM, Arleo S, Faini G. Distally Prophylactic Lymphaticovenular Anastomoses after Axillary or Inguinal Complete Lymph Node Dissection Followed by Radiotherapy: A Case Series. Medicina (B Aires) 2022; 58:medicina58020207. [PMID: 35208531 PMCID: PMC8880594 DOI: 10.3390/medicina58020207] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/29/2021] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Lymphedema is an important and underestimated condition, and this progressive chronic disease has serious implications on patients’ quality of life. The main goal of research would be to prevent lymphedema, instead of curing it. Patients receiving radiotherapy after lymph node dissection have a significantly higher risk of developing lymphedema. Through the prophylactic use of microsurgical lymphaticovenular anastomoses in selected patients, we could prevent the development of lymphedema. Materials and Methods: Six patients who underwent prophylactic lymphaticovenular anastomoses in a distal site to the axillary or groin region after axillary or inguinal complete lymph node dissection followed by radiotherapy were analyzed. Patients characteristics, comorbidities, operative details, postoperative complications and follow-up assessments were recorded. Results: Neither early nor late generic surgical complications were reported. We observed no lymphedema development throughout the post-surgical follow-up. In particular, we observed no increase in limb diameter measured at 1, 3, 6 and 12 months postoperatively. Conclusion: In our experience, performing LVA after axillary or groin lymphadenectomy and after adjuvant radiotherapy, and distally to the irradiated area, allows us to ensure the long-term patency of anastomoses in order to obtain the best results in terms of reducing the risk of iatrogenic lymphedema. This preliminary report is encouraging, and the adoption of our approach should be considered in selected patients.
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Affiliation(s)
- Diletta Maria Pierazzi
- Department of Medicine, Surgery and Neuroscience, Division of Plastic and Reconstructive Surgery, “Santa Maria alle Scotte” Hospital, University of Siena, 53100 Siena, Italy
- Correspondence:
| | - Sergio Arleo
- Department of Plastic Surgery, ASST Spedali Civili di Brescia, 25121 Brescia, Italy;
| | - Gianpaolo Faini
- Operative Unit of Reconstructive Microsurgery, Department of Surgery, ASST Valle Camonica, 25040 Brescia, Italy;
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The Combination of Lymph Node Transfer and Excisional Procedures in Bilateral Lower Extremity Lymphedema: Clinical Outcomes and Quality of Life Assessment with Long-Term Follow-Up. J Clin Med 2022; 11:jcm11030570. [PMID: 35160022 PMCID: PMC8836833 DOI: 10.3390/jcm11030570] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Bilateral lower extremity lymphedema is a rare and invalidating condition that poses a great challenge to the scientific community, and deeply affects the quality of life (QoL) of affected patients. A combined protocol consisting of lymph node transfer and a reductive method have never been reported for the treatment of this condition, except for small case series with brief follow-up periods. Methods: This retrospective study analyzed data of 29 patients, mean age 51 ± 17.1 years, who had been diagnosed with bilateral lower extremity lymphedema. Gastroepiploic vascularized lymph node transfer was performed in all the patients, and an excisional procedure was associated according to the clinical stage. Clinical history, circumferential limb measurements, complications, episodes of cellulitis, and responses to the Lymphedema Quality of Life Questionnaire were analyzed. Results: The mean follow-up was 38.4 ± 11.8 months. A significant reduction in the episodes of cellulitis per year was observed (p < 0.001). In our series, BMI and duration of symptoms were significantly related to the development of cellulitis during the postoperative period, p = 0.006 and p = 0.020, respectively. The LYMQoL questionnaire showed a significant quality of life improvement from 3.4 ± 0.9 to 6.2 ± 0.8 (p < 0.05). Conclusions: An integrated approach is essential for the treatment of bilateral lower extremity lymphedema: reductive and reconstructive methods are complementary to achieve a successful outcome. Timely treatment and BMI reduction are relevant in order to decrease the number of episodes of cellulitis. An attentive follow-up is necessary to identify recurrence and treat affected patients in time.
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Prevention of Secondary Lymphedema after Complete Lymph Node Dissection in Melanoma Patients: The Role of Preventive Multiple Lymphatic-Venous Anastomosis in Observational Era. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58010117. [PMID: 35056425 PMCID: PMC8778345 DOI: 10.3390/medicina58010117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/02/2022] [Accepted: 01/08/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Current guidelines have limited the performance of complete lymph node dissection (CLND) for patients with clinically detectable lymphatic metastases. Despite the limitations of this surgical procedure, secondary lymphedema (SL) is an unsolved problem that affects approximately 20% of patients undergoing CLND. Preventive lymphatic–venous micro-anastomoses (PMLVA) has already demonstrated its efficacy in the prevention of SL in melanoma patients with a positive sentinel lymph node biopsy (SLNB), but the efficacy of this procedure is not demonstrated in patients with clinically detectable lymphatic metastases. Materials and Methods: This retrospective cohort study, was performed in two observation periods. Until March 2018, CLND was proposed to all subjects with positive-SLNB andPMLVA was performed in a subgroup of patients with risk factors for SL (Group 1). From April 2018, according to the modification of melanoma guidelines, all patients with detectable metastatic lymph nodes underwent PMLVA during CLND (Group 2). The frequency of lymphedema in subjects undergoing PMLVA was compared with the control group. Results: Database evaluation revealed 172 patients with melanoma of the trunk with follow-up information for at least 6 mounts. Twenty-three patients underwent PMLVA during CLND until March 2018, 29 from April 2018, and 120 subjects underwent CLND without any preventive surgery (control Group). The frequency of SL was significantly lower in both Group 1 (4.3% vs. 24.2%, p = 0.03) and Group 2 (3.5%, p = 0.01). Patients undergoing PMLVA showed a similar recurrence-free periods and overall survival when compared to the control group. Conclusions: PMLVA significantly reduces the frequency of SL both in immediate and delayed CLND. This procedure is safe and does not lead to an increase in length of hospitalization.
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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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Stimulation of Synthesis and Lysis of Extracellular Matrix Proteins in Fibrosis Associated with Lymphedema. Dermatopathology (Basel) 2021; 9:1-10. [PMID: 35076482 PMCID: PMC8788559 DOI: 10.3390/dermatopathology9010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Fibrotic diseases pose a problem for overall health due to their chronic, progressive nature; the lack of a cure; and the fact that such conditions are largely refractory to current medical and surgical treatment practices. Objective: The aim of the present study was to report the physiological stimulation of synthesis and lysis of extracellular matrix proteins during the treatment of primary lymphedema. Material and Methods: A clinical trial was conducted involving the analysis of changes in type I and III collagen fibers and elastic fibers as well as the thickness of the epidermis and dermis in 10 histological fields. Samples were taken from the skin before and after intensive treatment using the Godoy Method® and adapted to the treatment of fibrosis in a patient with a clinical diagnosis of lower limb lymphedema. Slides were stained with orcein, hematoxylin and eosin, picrosirius red, and Gomori's reticulin stains. Weibel's multipoint method was used for the morphometric evaluation. The data were compared using the t-test with a 95% confidence interval. Results: Significant changes were detected in all aspects of interest (thickness of the epidermis and dermis, type I and III collagen fibers, and elastic fibers). Conclusion: The present findings demonstrate the physiological stimulation of synthesis and lysis of the main components of an extracellular matrix, such as type I and III collagen fibers and elastic fibers, as well as a reduction in the thickness of the epidermis and dermis in cases of fibrosis through adequate stimulation of the lymphatic system.
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Genital Lymphedema and How to Deal with It: Pearls and Pitfalls from over 38 Years of Experience with Unusual Lymphatic System Impairment. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111175. [PMID: 34833393 PMCID: PMC8618468 DOI: 10.3390/medicina57111175] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022]
Abstract
Background and Objectives: Conservative treatment represents an essential pillar of lymphedema management, along with debulking and physiologic surgeries. Despite the consistent number of treatment options, there is currently no agreement on their indications and possible combinations. When dealing with unusual lymphedema presentation as in the genitalia (Genital Lymphedema—GL), treatment choice becomes even more difficult. The authors aimed to present their targeted algorithm of single and combined treatment modalities for rare GL in order to face this paucity of information. Materials and Methods: Data were collected from a prospectively maintained database since January 1983, and cases of GL that were managed in the authors’ department were selected. Only patients that were treated in the authors’ institution and presented a minimum follow-up of 3 months were admitted to the current study. Results: From January 1983 to July 2021, 19 patients with GL were recruited. All the patients were male, and their ages ranged from 21 to 73 years old (average: 52). Ten cases (52.6%) presented with ISL (International Society of Lymphology) stage I, five (26.3%) were stage II and four (21.1%) were stage III. GL was managed with conservative treatment (12 cases), LVA (LymphaticoVenous Anastomosis) (3) or surgical excision (4). In a mean follow-up of 7.5 years (range: 3 months—11 years), no major complications occurred, and all cases reached improvements in functional and quality of life terms. Conclusions: Contrary to the predominant thought of the necessity to avoid surgery in unusual lymphedema presentations such as GL, they can be managed using targeted multimodal approaches or by adapting well-known procedures in unusual ways to achieve control of disease progression and improve patients’ quality of life.
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de Sire A, Inzitari MT, Moggio L, Pinto M, de Sire G, Supervia M, Petraroli A, Rubino M, Carbotti D, Succurro E, Ammendolia A, Andreozzi F. Effects of Intermittent Pneumatic Compression on Lower Limb Lymphedema in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Controlled Trial. ACTA ACUST UNITED AC 2021; 57:medicina57101018. [PMID: 34684055 PMCID: PMC8538573 DOI: 10.3390/medicina57101018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/21/2021] [Accepted: 09/22/2021] [Indexed: 01/13/2023]
Abstract
Background and Objectives: Diabetes mellitus type 2 (T2DM) is a chronic disease associated with fluid accumulation in the interstitial tissue. Manual lymphatic drainage (MLD) plays a role in reducing lymphoedema, like intermittent pneumatic compression (IPC). By the present pilot study, we aimed to evaluate the efficacy of a synergistic treatment with MLD and IPC in reducing lower limb lymphedema in T2DM patients. Materials and Methods: Adults with a clinical diagnosis of T2DM and lower limb lymphedema (stage II-IV) were recruited from July to December 2020. Study participants were randomized into two groups: experimental group, undergoing a 1-month rehabilitative program consisting of MLD and IPC (with a compression of 60 to 80 mmHg); control group, undergoing MLD and a sham IPC (with compression of <30 mmHg). The primary outcome was the lower limb lymphedema reduction, assessed by the circumferential method (CM). Secondary outcomes were: passive range of motion (pROM) of hip, knee, and ankle; quality of life; laboratory exams as fasting plasma glucose and HbA1c. At baseline (T0) and at the end of the 1-month rehabilitative treatment (T1), all the outcome measures were assessed, except for the Hb1Ac evaluated after three months. Results: Out of 66 T2DM patients recruited, only 30 respected the eligibility criteria and were randomly allocated into 2 groups: experimental group (n = 15; mean age: 54.2 ± 4.9 years) and control group (n = 15; mean age: 54.0 ± 5.5 years). At the intra-group analysis, the experimental group showed a statistically significant improvement of all outcome measures (p < 0.05). The between-group analysis showed a statistically significant improvement in pROM of the hip, knee, ankle, EQ-VAS, and EQ5D3L index at T1. Conclusions: A multimodal approach consisting of IPC and MLD showed to play a role in reducing lower limb lymphedema, with an increase of pROM and HRQoL. Since these are preliminary data, further studies are needed.
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Affiliation(s)
- Alessandro de Sire
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.T.I.); (A.P.); (A.A.)
- Correspondence: (A.d.S.); (L.M.); Tel.: +39-0961712819 (A.d.S.); +39-0961712211 (L.M.)
| | - Maria Teresa Inzitari
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.T.I.); (A.P.); (A.A.)
| | - Lucrezia Moggio
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.T.I.); (A.P.); (A.A.)
- Correspondence: (A.d.S.); (L.M.); Tel.: +39-0961712819 (A.d.S.); +39-0961712211 (L.M.)
| | - Monica Pinto
- Rehabilitation Medicine Unit, Strategic Health Services Department, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, 80131 Napoli, Italy;
| | - Giustino de Sire
- Medical Clinic “D.S.G.”, Caserta Local Health Service, 81100 Caserta, Italy;
| | - Marta Supervia
- Gregorio Marañón General University Hospital, Gregorio Marañón Health Research Institute, Dr. Esquerdo 46, 28007 Madrid, Spain;
- Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Annalisa Petraroli
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.T.I.); (A.P.); (A.A.)
| | - Mariangela Rubino
- Internal Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.R.); (D.C.); (E.S.); (F.A.)
| | - Delia Carbotti
- Internal Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.R.); (D.C.); (E.S.); (F.A.)
| | - Elena Succurro
- Internal Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.R.); (D.C.); (E.S.); (F.A.)
| | - Antonio Ammendolia
- Physical Medicine and Rehabilitation Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.T.I.); (A.P.); (A.A.)
| | - Francesco Andreozzi
- Internal Medicine Unit, Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (M.R.); (D.C.); (E.S.); (F.A.)
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