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Wei M, Wang L, Wu X, Wu B, Xiao S, Zhang Y, Min P, Deng C. Synchronous supraclavicular vascularized lymph node transfer and liposuction for gynecological cancer-related lower extremity lymphedema: A clinical comparative analysis of three different procedures. J Vasc Surg Venous Lymphat Disord 2024; 12:101905. [PMID: 38761979 DOI: 10.1016/j.jvsv.2024.101905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/08/2024] [Accepted: 04/23/2024] [Indexed: 05/20/2024]
Abstract
OBJECTIVE Gynecological cancer-related lower extremity lymphedema (GC-LEL), a chronic, progressive condition, lacks a standardized treatment. Currently, supraclavicular vascularized lymph node transfer (SC-VLNT) is a favored approach in the treatment of lymphedema, and there is a trend toward combination technology. This study conducts a comparative analysis of three techniques for treating GC-LEL with simultaneous SC-VLNT and liposuction. METHODS A cohort of 35 patients with GC-LEL was examined, comprising 13 patients who underwent single lymph nodes flap with a skin paddle (SLNF+P), 12 who received single lymph nodes flap without a skin paddle (SLNF), and 10 who accepted dual lymph nodes flap without a skin paddle (DLNF). Patient demographics and outcomes were meticulously documented, covering intra- and postoperative variables. RESULTS The median limb volume reduction were 56.4% (SLNF+P), 60.8% (SLNF), and 50.5% (DLNF) in stage II, and 54.0% (SLNF+P), 59.8% (SLNF), and 54.4% (DLNF) in stage III. DLNF group procedures entailed longer flap harvesting and transplantation times. The SLNF+P group, on average, had an 8-day postoperative hospitalization, longer than others. All patients noted subjective improvements in Lymphedema Quality of Life scores, with lymphoscintigraphy revealing enhanced lymphatic flow in 29 of the 35 cases. A notable decrease in cellulitis incidence was observed. Additionally, the occurrence of cellulitis decreased significantly, except for DLNF (Stage Ⅱ). The median follow-up time was 16 months (range, 12-36 months), with no reported severe postoperative complications. CONCLUSIONS For advanced GC-LEL, SLNF combined with liposuction is a preferred treatment, offering fewer complications, shorter operative time, and hospitalization.
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Affiliation(s)
- Miaomiao Wei
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Liangliang Wang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Xiangkui Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Bihua Wu
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Shune Xiao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Peiru Min
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Chengliang Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China; Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China.
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Nilforoushzadeh MA, Heidari A, Ghane Y, Heidari N, Azizi H, Fakhim T, Shahverdi M, Rafiee S, Lotfi Z, Najar Nobari N. The Endo-lift Laser (Intralesional 1470 nm Diode Laser) for Dermatological Aesthetic Conditions: A Systematic Review. Aesthetic Plast Surg 2024:10.1007/s00266-024-04082-2. [PMID: 38886198 DOI: 10.1007/s00266-024-04082-2] [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: 12/21/2023] [Accepted: 04/09/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The prominence of minimally invasive aesthetic approaches has become increasingly pivotal. The endo-lift laser method is an intralesional 1470 nm diode laser connected to a fiber that serves both therapeutic and aesthetic properties. We sought to evaluate the efficacy and safety of the endo-lift laser method for dermatological aesthetic applications. METHODS PubMed, Ovid-Embase, and Web of Science were systematically searched up to November 5th, 2023. A citation search was also performed. The National Institute of Health (NIH) Quality Assessment Tool was used to evaluate the quality of the studies. RESULTS Out of 339 articles, twenty-three relevant studies were included in the current review. Applying the endo-lift laser method for rejuvenation, including face and neck lifting, enhancing skin laxity, and disappearing wrinkles, folds, and lines, demonstrated favorable efficacy and safety profile. Moreover, most studies have shown that the endo-lift laser method is promising in eliminating the adipose tissue in the jowl, abdomen, thighs, and arms. The endo-lift laser technique was also efficacious in nose remodeling and blepharoplastic procedures, including treating eyelid and eyebrow ptosis, eye bag, eyebrow position, and eyelid laxity. Patients who suffer from several diseases, such as hidradenitis suppurativa, progressive lipodystrophy, acne vulgaris, scars, and keloids, benefit from procedural treatment with the endo-lift laser technique. Across all studies, the adverse events were mild and self-limiting. Investigating the endo-lift laser method in all aesthetic and therapeutic indications resulted in high patient satisfaction rates. CONCLUSION The endo-lift laser technique has therapeutic effects and is recommended for various dermatological aesthetic indications. Further clinical studies with control groups and larger sample sizes are needed to acquire more reliable evidence. LEVELS OF EVIDENCE III AND IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Mohammad Ali Nilforoushzadeh
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Yekta Ghane
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nazila Heidari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hanieh Azizi
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Tannaz Fakhim
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
| | - Mohammadhasan Shahverdi
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
| | - Shohreh Rafiee
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
| | - Zahra Lotfi
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran
| | - Niloufar Najar Nobari
- Skin Repair Research Center, Shahid Beheshti University of Medical Sciences, Ahmadi Alley, Mirdamad, Nelson Mandela St. 1518963113, Tehran, Iran.
- Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran.
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Li K, Nicoli F, Cui C, Wo Y, Liu NF, Feng S, Xi W, Min P, Zhang Y. Vascularized lymph node flaps can survive on venous blood without an arterial inflow: an experimental model describing the dynamics of venous flow using indocyanine green angiography (With video). BURNS & TRAUMA 2023; 11:tkad019. [PMID: 37476580 PMCID: PMC10355992 DOI: 10.1093/burnst/tkad019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/28/2023] [Accepted: 03/22/2023] [Indexed: 07/22/2023]
Abstract
Background Several surgeons have described studies of free-tissue transfers using veins instead of arteries. These innovative microsurgical techniques can offer several advantages, such as an easier dissection during flap harvesting, and represent an alternative during an accidental surgical mistake or development of new surgical procedures. The purpose of this study was to describe and explore different constructs of vascularized lymph node transfer (VLNT) only based on venous blood flow in a mouse model, evaluate their blood flow microcirculation through indocyanine green (ICG) angiography and investigate the lymphatic drainage function and the lymph nodes' structures. Methods Five types of venous lymph node flaps (LNF) were created and investigated: Types IA, IB, IC, IIA and IIB were developed by ICG intraoperatively (with videos in the article). Seven weeks later, by applying methylene blue, the recanalization of the lymphatic vessels between the LNF and the recipient site was detected. Lymph nodes were collected at the same time and their structures were analyzed by hematoxylin and eosin staining analysis. Results All of the venous LNFs developed except Type IC. Seven weeks later, methylene blue flowed into Types IA, IB, IIA and IIB from recipient sites. When comparing with arteriovenous lymph node, the medullary sinus was diffusely distributed in venous lymph nodes. The proportion of cells was significantly reduced (p < 0.05). The artery diameters were significantly smaller (p < 0.05). The veins diameters and lymphatic vessels output in Types IA, IB, IIA and IIB were more dilated (p < 0.05). Conclusions This research demonstrated that Type IA, IB, IIA and IIB venous LNFs can retrogradely receive venous blood supply; they can survive, produce a lymphatic recanalization and integrate with the surrounding tissue, despite lymph node structural changes. Our results will improve the understanding of the survival mechanism of venous LNFs and will help researchers to design new studies or lymphatic models and eventually find an alternative procedure for the surgical treatment of lymphedema.
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Affiliation(s)
| | | | | | - Yan Wo
- Department of Anatomy and Physiology, School of Medicine, Shanghai Jiao Tong University, Shanghai 200000, P. R. China
| | - Ning Fei Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200000, China
| | - Shaoqing Feng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200000, China
| | - Wenjing Xi
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai JiaoTong University School of Medicine, Shanghai 200000, China
| | - Peiru Min
- Correspondence. Peiru Min, ; Yixin Zhang,
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Ciudad P, Bolletta A, Kaciulyte J, Losco L, Manrique OJ, Cigna E, Mayer HF, Escandón JM. The breast cancer-related lymphedema multidisciplinary approach: Algorithm for conservative and multimodal surgical treatment. Microsurgery 2023; 43:427-436. [PMID: 36433802 DOI: 10.1002/micr.30990] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/17/2022] [Accepted: 11/18/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple surgical alternatives are available to treat breast cancer-related lymphedema (BCRL) providing a variable spectrum of outcomes. This study aimed to present the breast cancer-related lymphedema multidisciplinary approach (B-LYMA) to systematically treat BCRL. METHODS Seventy-eight patients presenting with BCRL between 2017 and 2021 were included. The average age and BMI were 49.4 ± 7.8 years and 28.1 ± 3.5 kg/m2 , respectively. Forty patients had lymphedema ISL stage II (51.3%) and 38 had stage III (48.7%). The mean follow-up was 26.4 months. Treatment was selected according to the B-LYMA algorithm, which aims to combine physiologic and excisional procedures according to the preoperative evaluation of patients. All patients had pre- and postoperative complex decongestive therapy (CDT). RESULTS Stage II patients were treated with lymphaticovenous anastomosis (LVA) (n = 18), vascularized lymph node transfer (VLNT) (n = 12), and combined DIEP flap and VLNT (n = 10). Stage III patients underwent combined suction-assisted lipectomy (SAL) and LVA (n = 36) or combined SAL and VLNT (n = 2). Circumferential reduction rates (CRR) were comparable between patients treated with LVA (56.5 ± 8.4%), VLNT (54.4 ± 10.2%), and combined VLNT-DIEP flap (56.5 ± 3.9%) (p > .05). In comparison to LVA, VLNT, and combined VLNT-DIEP flap, combined SAL-LVA exhibited higher CRRs (85 ± 10.5%, p < .001). The CRR for combined SAL-VLNT was 75 ± 8.5%. One VLNT failed and minor complications occurred in the combined DIEP-VLNT group. CONCLUSION The B-LYMA protocol directs the treatment of BCRL according to the lymphatic system's condition. In advanced stages where a single physiologic procedure is not sufficient, additional excisional surgery is implemented. Preoperative and postoperative CDT is mandatory to improve the outcomes.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Juste Kaciulyte
- Department of Surgery "P.Valdoni", Unit of Plastic and Reconstructive Surgery, Sapienza University of Rome, Rome, Italy
| | - Luigi Losco
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Horacio F Mayer
- Plastic Surgery Department, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Buenos Aires, Argentina
| | - Joseph M Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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Comparison of the Effectiveness of Liposuction for Lower Limb versus Upper Limb Lymphedema. J Clin Med 2023; 12:jcm12051727. [PMID: 36902514 PMCID: PMC10003574 DOI: 10.3390/jcm12051727] [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: 12/23/2022] [Revised: 01/24/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Liposuction is the most frequently performed debulking procedure in patients with lymphedema. However, it remains uncertain whether liposuction is equally effective for upper extremity lymphedema (UEL) and lower extremity lymphedema (LEL). In this study, we retrospectively compared the effectiveness of liposuction according to whether it was performed for LEL or UEL, and identified factors associated with outcomes. MATERIALS AND METHODS All patients had been treated at least once by lymphovenous anastomosis or vascularized lymphatic transplant before liposuction but without sufficient volume reduction. The patients were divided into an LEL group and a UEL group, and then subdivided further according to whether they completed their planned compression therapy into an LEL compliance group, an LEL non-compliance group, a UEL compliance group, and a UEL non-compliance group. The reduction rates in LEL (REL) and in UEL (REU) were compared between the groups. RESULTS In total, 28 patients with unilateral lymphedema were enrolled (LEL compliance group, n = 12; LEL non-compliance group, n = 6; UEL compliance group, n = 10; UEL non-compliance group, n = 0). The non-compliance rate was significantly higher in the LEL group than in the UEL group (p = 0.04). REU was significantly higher than REL (100.1 ± 37.3% vs. 59.3 ± 49.4%; p = 0.03); however, there was no significant difference between REL in the LEL compliance group (86 ± 31%) and REU in the UEL group (101 ± 37%) (p = 0.32). CONCLUSION Liposuction seems to be more effective in UEL than in LEL, probably because the compression therapy required for management after liposuction is easier to implement for UEL. The lower pressure and smaller coverage area required for postoperative management after liposuction in the upper limb may explain why liposuction is more effective in UEL than in LEL.
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Transcutaneous Electrical Acupoint Stimulation Combined with Warm Acupuncture for Breast Cancer Related Upper Limb Lymphedema: A Retrospective Cohort Study. Chin J Integr Med 2022; 29:534-539. [DOI: 10.1007/s11655-022-3684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/16/2022]
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Manrique OJ, Bustos SS, Ciudad P, Adabi K, Chen WF, Forte AJ, Cheville AL, Jakub JW, McLaughlin SA, Chen HC. Overview of Lymphedema for Physicians and Other Clinicians: A Review of Fundamental Concepts. Mayo Clin Proc 2022; 97:1920-1935. [PMID: 32829905 DOI: 10.1016/j.mayocp.2020.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
Lymphedema has historically been underrated in clinical practice, education, and scholarship to the detriment of many patients with this chronic, debilitating condition. The mechanical insufficiency of the lymphatic system causes the abnormal accumulation of protein-rich fluid in the interstitium, which triggers a cascade of adverse consequences such as fat deposition and fibrosis. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Correspondingly, lymphedema results in psychological morbidity, including anxiety, depression, social avoidance, and a decreased quality of life, encompassing emotional, functional, physical, and social domains. For this review, we conducted a literature search using PubMed and EMBASE and herein summarize the evidence related to the fundamental concepts of lymphedema. This article aims to raise awareness of this serious condition and outline and review the fundamental concepts of lymphedema.
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Affiliation(s)
- Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Kian Adabi
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN
| | - Wei F Chen
- Division of Plastic and Reconstructive Surgery, University of Iowa, Iowa City
| | | | - Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | | | | | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Brown S, Mehrara BJ, Coriddi M, McGrath L, Cavalli M, Dayan JH. A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant. Ann Surg 2022; 276:635-653. [PMID: 35837897 PMCID: PMC9463125 DOI: 10.1097/sla.0000000000005591] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. METHODS This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. RESULTS There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. CONCLUSIONS VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
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Affiliation(s)
- Stav Brown
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Viviano SL, Neligan PC. Updates on Excisional Procedures for Lymphedema. Adv Wound Care (New Rochelle) 2022; 11:419-427. [PMID: 34128393 DOI: 10.1089/wound.2021.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Significance: Excisional procedures for lymphedema have been used for over a century, and many surgeons have abandoned the old techniques as improvements in nonsurgical management and microsurgery have limited their clinical utility. Nonetheless, excisional procedures remain relevant as an important tool in the comprehensive surgical management of lymphedema. Recent Advances: Modifications to the Charles procedure and other direct excisional procedures have improved the complication profile and patient outcomes. Moreover, the use of liposuction techniques for minimally invasive tissue excision has expanded the scope of excisional surgery to benefit patients with less severe lymphedema. Recent operations combining excisional and physiologic procedures may prove to have superior results to stand-alone procedures. Critical Issues: No standard protocol exists for the comprehensive surgical management of lymphedema. Proper patient selection for any procedure requires robust outpatient assessment, cooperation with physiotherapy treatment teams, careful patient stratification, and a clear understanding of the procedure's goal. Future Directions: Larger, prospective trials will be needed to elucidate the ideal timing and combinations of techniques to optimize outcomes for patients with late-stage lymphedema.
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Affiliation(s)
- Stephen L Viviano
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Peter C Neligan
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, Washington, USA
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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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Lasso JM, Alonso-Farto JC. Indocyanine green-guided liposuction for patients presenting with residual nonpitting edema after lymphovenous anastomosis. J Plast Reconstr Aesthet Surg 2022; 75:2482-2492. [PMID: 35387757 DOI: 10.1016/j.bjps.2022.02.081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 12/24/2021] [Accepted: 02/22/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction. PATIENTS AND METHOD Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry. RESULTS The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12). CONCLUSION Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%.
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Affiliation(s)
- J M Lasso
- Department of Plastic and Reconstructive Surgery, Hospital Genertal Universitario Gregorio Marañón, Universidad Complutense de Madrid, Spain.
| | - J C Alonso-Farto
- Department of Nuclear Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Heller L, Menashe S, Plonski L, Ofek A, Pozner JN. 1470-nm Radial fiber-assisted liposuction for body contouring and facial fat grafting. J Cosmet Dermatol 2022; 21:1514-1522. [PMID: 35106886 PMCID: PMC9303361 DOI: 10.1111/jocd.14767] [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: 10/25/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 12/01/2022]
Abstract
Background Laser‐assisted liposuction using 1470‐nm radial fiber emits light energy preferentially absorbed by water, yielding a rapid and localized contouring and tightening effect, with minimal scarring. When collected under appropriate conditions, extracted fat samples can be exploited as autologous filling material in liposculpturing procedures. Objectives To assess the 6‐month contouring efficacy of 1470 radial fiber‐assisted liposuction and the volumetric enhancement effect of the harvested tissue in facial fat grafting. Methods Twenty subjects underwent liposuction (BeautiFill, Alma Lasers, Inc.) of lower abdominal or outer thigh fat. In seven subjects, harvested samples were grafted into facial regions. Treatment safety, body weight, blinded evaluator‐assessed aesthetic improvements, and subject‐rated satisfaction were monitored for 6 months. Abdominal and facial fat thickness were assessed by magnetic resonance imaging (n = 5) within 3 months of treatment. Results One‐month posttreatment, most subjects ranked improvements good/excellent (88%) and skin tightening satisfactory/very satisfactory (92%), with >70% of subjects providing similar scores 6‐month posttreatment. Blinded evaluators noted improved/very much improved aesthetic appearance (87%). Harvested tissue injected as a facial filler (21.0 ± 5.2 ml) led to a 0.63 ± 0.12 mm increase in facial fat thickness, observed by MRI, within 3 months. Six months postfilling, the majority of subjects (83%) were satisfied with the outcome. All procedures were well‐tolerated. Conclusions A single 1470 nm radial fiber‐assisted abdominal and thigh liposuction session provided for effective and durable reduction of adipose tissue deposits, with appreciable skin tightening and aesthetic improvements. The gentle harvesting method yielded viable filler material, which was well‐retained in facial regions for up to 6 months.
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Affiliation(s)
- Lior Heller
- Department of Plastic Surgery, Shamir Medical Center, Zerifin, Israel
| | - Shaked Menashe
- Department of Plastic Surgery, Shamir Medical Center, Zerifin, Israel
| | - Lori Plonski
- Department of Plastic Surgery, Shamir Medical Center, Zerifin, Israel
| | - Andre Ofek
- Department of Plastic Surgery, Shamir Medical Center, Zerifin, Israel
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Multimodality Approach to Lymphedema Surgery Achieves and Maintains Normal Limb Volumes: A Treatment Algorithm to Optimize Outcomes. J Clin Med 2022; 11:jcm11030598. [PMID: 35160049 PMCID: PMC8836570 DOI: 10.3390/jcm11030598] [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: 11/29/2021] [Revised: 01/15/2022] [Accepted: 01/21/2022] [Indexed: 11/17/2022] Open
Abstract
Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridgeTM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridgeTM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (−4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to −1.0% (−3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.
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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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15
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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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Brazio PS, Nguyen DH. Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes. Ann Plast Surg 2021; 86:S384-S389. [PMID: 33976067 DOI: 10.1097/sap.0000000000002695] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema. METHODS We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone. RESULTS Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence. CONCLUSION Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures.
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Affiliation(s)
- Philip S Brazio
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
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17
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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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Treatment of hypertrophic scars and keloids using an intralesional 1470 nm bare-fibre diode laser: a novel efficient minimally-invasive technique. Sci Rep 2020; 10:21694. [PMID: 33303965 PMCID: PMC7728807 DOI: 10.1038/s41598-020-78738-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/26/2020] [Indexed: 12/20/2022] Open
Abstract
Hypertrophic and keloid scars result from abnormal wound healing and can have a variable response to a number of available treatment modalities. The evolution of laser treatments in recent years has shown a wide range of clinical applications including their use in the treatment of scars. We investigated the effectiveness of a 1470 nm diode laser using an intralesional optical fibre delivery device in the treatment of hypertrophic and keloid scars. We evaluated its safety and efficacy as a novel and minimally invasive treatment alternative for scar modulation and volume reduction. A prospective cohort study was performed involving 21 patients with hypertrophic scars (HS) (n = 9) and keloids (n = 12) resulting from various aetiology. Patients were treated with one to three treatment sessions. Comprehensive evaluations were performed using the Vancouver Scar Scale, Doppler ultrasound, Cutometer, Mexameter and PeriCam PSI. Scar thickness was reduced by an average of 0.308 ± 0.138 cm (p < 0.001). In particular the two subgroups showed a significant 27.7% and 28.2% reduction in scar thickness of HS and Keloids, respectively. Scar firmness showed a significant improvement of 1.2% (p < 0.05) for HS, though for keloids this was 0.4% (p = 0.26). Keloids had a significant reduction in pigmentation at 21.3%. Blood perfusion had a significant reduction of 29.6% in HS and 22.7% in Keloids. Overall VSS total score improvement of 42% in the HS and at 37.9% in the Keloid subgroup. No adverse events such as hypo/hyperpigmentation, skin infection, or recurrence were reported. This study shows that the intralesional 1470 nm bare-fibre diode laser significantly improved hypertrophic and keloid scars based on both subjective and objective analyses and supports this type of laser therapy as a safe and effective minimally-invasive treatment option.
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19
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Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
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Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
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20
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21
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Jeon BJ, Chang DW. Breast cancer related lymphedema and surgical treatment. PRECISION AND FUTURE MEDICINE 2020. [DOI: 10.23838/pfm.2020.00065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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22
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Ciudad P, Manrique OJ, Bustos SS, Agko M, Huang TCT, Vizcarra L, Nuñez ML, Lo Torto F, Forte AJ. Single-stage VASER-assisted liposuction and lymphatico-venous anastomoses for the treatment of extremity lymphedema: a case series and systematic review of the literature. Gland Surg 2020; 9:545-557. [PMID: 32420290 DOI: 10.21037/gs.2020.01.13] [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] [Indexed: 12/29/2022]
Abstract
Background A paradigm shift towards the use of combined physiological and excisional surgical approaches for the treatment of lymphedema is permeating the surgical practice worldwide. We describe a single-stage surgical approach combining-vaser assisted liposuction (VAL) and lymphatico-venous anastomoses (LVA) for the treatment of extremity-lymphedema. Methods Between March 2018 and March 2019, a retrospective review of patients with extremity-lymphedema stage IIb-III International Society of Lymphology who underwent the combined technique was done. Demographics, operative characteristics, clinical outcomes and complications were assessed. Additionally, a systematic review of studies that reported combined physiological procedures with liposuction for the treatment of lymphedema was conducted. Results A total of 24 patients [12 upper extremity lymphedema (UEL), and 12 lower extremity lymphedema (LEL)] were included and analyzed. The mean age was 54.5 years (38-72 years). The mean circumference reduction rate was 90% and 85% for UEL and LEL, respectively. Infection rate decreased to zero postoperatively in all patients. Ten studies were included in the review: six pooling 220 cases included two-stage procedures, and four pooling 66 cases described one-stage surgeries. All patients who underwent a combined approach reported clinical improvement. Conclusions Our combined approach is safe surgical option and allows adequate limb size reduction with faster recovery in selected patients with lymphedema with strong fibroadipose component.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Institute of Plastic, Reconstructive and Aesthetic Surgery, Ciruesthetic, Clinic, Lima, Peru
| | - 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
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | | | - Luis Vizcarra
- Institute of Plastic, Reconstructive and Aesthetic Surgery, Ciruesthetic, Clinic, Lima, Peru
| | | | - Federico Lo Torto
- Department of Surgery "Pietro Valdoni", Plastic Surgery Unit, Sapienza University of Rome, Rome, Italy
| | - Antonio J Forte
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, FL, USA
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23
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Park KE, Allam O, Chandler L, Mozzafari MA, Ly C, Lu X, Persing JA. Surgical management of lymphedema: a review of current literature. Gland Surg 2020; 9:503-511. [PMID: 32420285 DOI: 10.21037/gs.2020.03.14] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Lymphedema may be characterized by a progressive clinical course and limitations in improvement despite multi-modality treatment. In westernized countries, it most commonly presents as an undesirable complication of cancer treatment, particularly breast cancer. In the past several decades, surgical treatments for lymphedema have advanced, alongside developments in microsurgery. Lymphovenous anastomosis (LVA) and lymph node transplantation are physiological therapies that may reduce lymphedema through addressing its route cause. Ablative techniques such as liposuction and subcutaneous excision aid in resolving the accumulation of proteinaceous adipose and fibrotic tissue seen in advanced lymphedema. The goal of this review is to examine the outcomes and limitations of current surgical techniques used in lymphedema management.
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Affiliation(s)
- Kitae E Park
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Omar Allam
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Ludmila Chandler
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Mohammad Ali Mozzafari
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Catherine Ly
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Xiaona Lu
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - John A Persing
- Division of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT, USA
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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: 15] [Impact Index Per Article: 3.8] [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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Forte AJ, Huayllani MT, Boczar D, Ciudad P, Manrique O. Lipoaspiration and Lymph Node Transfer for Treatment of Breast Cancer-related Lymphedema: A Systematic Review. Cureus 2019; 11:e6096. [PMID: 31723482 PMCID: PMC6844538 DOI: 10.7759/cureus.6096] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Lipoaspiration and venous lymph node transfer have each been described as procedures that would improve symptoms of lymphedema. We aim to describe the efficacy of the combination of lipoaspiration and lymph node transfer and to report the outcomes in breast cancer-related lymphedema patients. The search was conducted by querying the PubMed, EMBASE, and Ovid Medline databases for studies that considered the use of lipoaspiration and venous lymph node transfer as surgical treatment for breast cancer-related lymphedema. Different combinations of the keywords “aspiration lipectomy” AND “lymphedema” AND “lymph node transfer” were used for the search. From a total of 20 articles, five met inclusion criteria. All patients included in these studies had stage II or III lymphedema. Two studies considered lipoaspiration as the first step followed by lymph node transfer, two considered lymph node transfer as the first step followed by lipoaspiration, and one applied both procedures simultaneously. A meaningful volume reduction was achieved in all cases. Patients who underwent lymph node transfer first followed by lipoaspiration appeared to have the best outcomes. This systematic review suggests that the combination of lymph node transfer and lipoaspiration is a potential surgical treatment that may improve outcomes achieved by one single procedure in patients with stage II to III breast cancer-related lymphedema.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Pedro Ciudad
- Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, PER
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27
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Ciudad P, Sabbagh MD, Agko M, Huang TCT, Manrique OJ, L CR, Reynaga C, Delgado R, Maruccia M, Chen HC. Surgical Management of Lower Extremity Lymphedema: A Comprehensive Review. Indian J Plast Surg 2019; 52:81-92. [PMID: 31456616 PMCID: PMC6664851 DOI: 10.1055/s-0039-1688537] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Lymphedema refers to the accumulation of protein-rich fluid in the interstitial spaces. This can occur secondary to congenital malformation of the lymphatic channels or nodes or as a result of an insult that damages appropriately formed channels and nodes. Stagnant, protein-rich lymph initiates an inflammatory response that leads to adipocyte proliferation, fibrous tissue deposition, and increased susceptibility to infections. The end result is permanent disfigurement and dermal changes. Early and accurate diagnosis is essential, since lymphedema is a chronic and progressive problem. When lymphedema affects the lower extremity, it is important to manage it in a way that preserves function and mobility. Early diagnosis also allows for a proactive rather than reactive approach to treatment and utilization of novel physiologic procedures, such as lymphovenous anastomosis and vascularized lymph node transfer. Such interventions slow down disease progression and reduce morbidity by allowing the surgeon to salvage the remaining functional lymphatic channels. When physiologic procedures fail or when faced with a delayed presentation, the addition of excisional procedures can provide a more comprehensive treatment of this debilitating disease. The aim of this article is to review the most current concepts in the surgical management of lower extremity lymphedema.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia
| | - Tony C T Huang
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, United Sates
| | - Carmen Román L
- Department of Physical and Rehabilitation Medicine, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Cesar Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Ricardo Delgado
- Department of Plastic and Reconstructive Surgery, National Cancer Institute of Peru (INEN), Lima, Peru
| | - Michele Maruccia
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Chilgar RM, Khade S, Chen HC, Ciudad P, Yeo MSW, Kiranantawat K, Maruccia M, Li K, Zhang YX, Nicoli F. Surgical Treatment of Advanced Lymphatic Filariasis of Lower Extremity Combining Vascularized Lymph Node Transfer and Excisional Procedures. Lymphat Res Biol 2019; 17:637-646. [PMID: 31038386 DOI: 10.1089/lrb.2018.0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lymphatic filariasis (LF) in advanced stage is a clinically challenging disability resulting in poor quality of life. In advanced stage of filariasis, medical management is seldom effective and few surgical procedures are beneficial. In this study, we assessed clinical efficacy of a surgical technique combining vascularized lymph node transfer (VLNT) and serial excision for patients affected by advanced LF. Patients and Methods: A total of 17 patients with grades 2 and 3 lower limb lymphedema after three consecutive humanitarian missions in India between 2014 and 2018 underwent excision of excessive soft tissue of leg and supraclavicular lymph node flap transferred to dorsum of foot. Recipient vessels were prepared and microanastomosis was performed. Lymphedema was assessed by measuring leg circumferences at different levels, episodes of infectious lymphangitis, and lymphoscintigraphy. Results: A significant decrease of lower limb circumference measurements at all levels was noted postoperatively. Postoperative lymphoscintigraphy revealed reduced lymph stasis. One patient suffered of a seroma on donor site. Six patients had partial loss of skin graft over the flap at recipient site and it was managed by regrafting. Data analysis observed statistically significant reduction in feeling of heaviness (p < 0.005) and episodes of acute lymphangitis after surgery. Conclusion: Advanced LF of leg is difficult to manage using traditional medical treatment. The combination of VLNT and surgical excision provided a safe and reliable approach to treat this debilitating disease.
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Affiliation(s)
- Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Sujit Khade
- Department of Plastic and Reconstructive Surgery, Elrevo Clinic, Aurangabad, India
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Matthew Sze-Wei Yeo
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Department of Plastic and Reconstructive Surgery, Newcastle Upon Tyne Hospitals, Newcastle Upon Tyne, United Kingdom
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30
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Ciudad P, Agko M, Huang TCT, Manrique OJ, Chang WL, Nicoli F, Maruccia M, Lo Torto F, Chen HC. Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,’ Homan’s, and vascularized lymph node transfer (CHAHOVA) procedures. J Surg Oncol 2019; 119:430-438. [PMID: 30613978 DOI: 10.1002/jso.25356] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/16/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Burn Surgery; Arzobispo Loayza National Hospital; Lima Peru
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Section of Plastic Surgery; Medical College of Georgia, Augusta University; Augusta Georgia
| | - Tony C. T. Huang
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery; National Cancer Institute of Peru (INEN); Lima Peru
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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31
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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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32
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Nicoli F, Orfaniotis G, Li K, Zhang YX, Chen HC. Reply to Tsukuura et al: "Novel hands-free near-infrared fluorescence navigation and simultaneous combined imaging for the elevation of vascularized lymph node flap". J Surg Oncol 2018; 118:590. [PMID: 30187479 DOI: 10.1002/jso.25134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata,", Rome, Italy.,Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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33
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Gould DJ, Mehrara BJ, Neligan P, Cheng MH, Patel KM. Lymph node transplantation for the treatment of lymphedema. J Surg Oncol 2018; 118:736-742. [PMID: 30129675 DOI: 10.1002/jso.25180] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/05/2022]
Abstract
Lymphedema is a complex disease process with deranged lymphatic transport, fluid accumulation and secondary lipedema and fibrosis. This is a challenging disease to treat with a surgical focus on debulking and physiologic strategies. One strategy is the use of vascularized lymph node transplant (VLNT) to improve physiologic lymph clearance. In this article, VLNT is discussed in detail, including mechanisms, combined strategies, and outcomes.
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Affiliation(s)
- Daniel J Gould
- Division of Plastic and Reconstructive Surgery, University of Southern California, California
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery, Service, Memorial Sloan-Kettering Cancer Center, New York
| | - Peter Neligan
- Department of Plastic Surgery, University of Washington Medical Center, Washington
| | - Ming-Huei Cheng
- Department of Plastic and Reconstructive Surgery, Division of Reconstructive Microsurgery, Chang Gung Memorial Hospital, Taiwan
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, University of Southern California, California
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34
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Li K, Zhang Z, Liu NF, Sadigh P, Evans VJ, Zhou H, Gao W, Zhang YX. Far-Infrared Radiation Thermotherapy Improves Tissue Fibrosis in Chronic Extremity Lymphedema. Lymphat Res Biol 2018; 16:248-257. [PMID: 28961078 DOI: 10.1089/lrb.2016.0057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zheng Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ning Fei Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Parviz Sadigh
- Department of Plastic Reconstructive Surgery, The Royal London Hospital, London, United Kingdom
| | - Verity Joyce Evans
- Department of Plastic Reconstructive Surgery, The Royal London Hospital, London, United Kingdom
| | - Huihong Zhou
- Department of Ultrasound, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Weiqing Gao
- Department of Radiology, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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35
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Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH. Vascularized Lymph Node Transfer for Lymphedema. Semin Plast Surg 2018; 32:28-35. [PMID: 29636651 DOI: 10.1055/s-0038-1632401] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.
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Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ido Badash
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ketan M Patel
- Division of Plastic and Reconstructive Surgery, Keck Medical Center of USC, University of Southern California, Los Angeles, California
| | - Jesse C Selber
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ming-Huei Cheng
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
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36
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37
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Nicoli F, Orfaniotis G, Ciudad P, Kiranantawat K, Lazzeri D, Maruccia M, Constantinides J, Sacak B, Chilgar RM, Li K, Zhang YX, Chen HC. Alternative vascular constructs of lymph node flap transfer. J Surg Oncol 2018; 117:1144-1147. [PMID: 29355962 DOI: 10.1002/jso.24966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 12/08/2017] [Indexed: 11/09/2022]
Abstract
Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.
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Affiliation(s)
- Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy.,Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, United Kingdom
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, United Kingdom
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Faculty of Medicine Ramathibodi Hospital, Department of Plastic and Maxillofacial Surgery, Mahidol University, Bangkok, Thailand
| | - Davide Lazzeri
- Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Joannis Constantinides
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, United Kingdom
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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38
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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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39
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40
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Garza R, Skoracki R, Hock K, Povoski SP. A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies. BMC Cancer 2017; 17:468. [PMID: 28679373 PMCID: PMC5497342 DOI: 10.1186/s12885-017-3444-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 06/22/2017] [Indexed: 01/12/2023] Open
Abstract
Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities.
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Affiliation(s)
- Ramon Garza
- PRMA Plastic Surgery, San Antonio, TX 78240 USA
| | - Roman Skoracki
- Department of Plastic Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA
| | - Karen Hock
- Division of Oncology Rehabilitation Services, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA
| | - Stephen P. Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH 43210 USA
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41
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Efficacy and safety of far infrared radiation in lymphedema treatment: clinical evaluation and laboratory analysis. Lasers Med Sci 2017; 32:485-494. [DOI: 10.1007/s10103-016-2135-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/21/2016] [Indexed: 01/10/2023]
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42
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Li K, Liu N, Yu Z, Sadigh P, Lazzeri D, Zhang YX. Heating and Compression Bandage Treatment Is Effective for Chronic Lymphedema with Dermatolymphangioadenitis—A Case-Controlled Study. Lymphat Res Biol 2016; 14:233-239. [PMID: 27267348 DOI: 10.1089/lrb.2015.0054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ke Li
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ningfei Liu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Ziyou Yu
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Parviz Sadigh
- The Royal London Hospital, Department of Plastic Reconstructive Surgery, London, United Kingdom
| | - Davide Lazzeri
- Plastic Reconstructive and Aesthetic Surgery Unit, Villa Salaria Clinic, Rome, Italy
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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43
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Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review. J Plast Reconstr Aesthet Surg 2016; 69:1234-47. [DOI: 10.1016/j.bjps.2016.06.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/18/2016] [Accepted: 06/22/2016] [Indexed: 11/17/2022]
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44
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Ciudad P, Manrique OJ, Date S, Sacak B, Chang WL, Kiranantawat K, Lim SY, Chen HC. A head-to-head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6-year single center experience. J Surg Oncol 2016; 115:37-42. [PMID: 27440739 DOI: 10.1002/jso.24349] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 06/15/2016] [Indexed: 11/10/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Seong Yoon Lim
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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45
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Cornelissen AJM, Qiu SS, Lopez Penha T, Keuter X, Piatkowski de Grzymala A, Tuinder S, van der Hulst R. Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature. J Surg Oncol 2016; 115:32-36. [PMID: 27383039 DOI: 10.1002/jso.24342] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/14/2016] [Indexed: 01/26/2023]
Abstract
Lymph node transfer has been performed to treat lymphedema for several years. The goal of this procedure is to provide a bridge between the lymphatic system distal and proximal to the lymph node dissection. There is a lack of consensus about the necessity of an additional vascular anastomosis for the transplanted lymph nodes. A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE of animal studies using lymph node transplantation with and without additional vascularization was performed in March 2016. The strategy used for the search was: (("Models, Animal"[Mesh]) AND (("Lymphedema"[Mesh]) OR "Lymph Nodes"[Mesh]) OR "Lymph Node Excision"[Mesh])) AND ((vascularized lymph node transfer) OR ((non-vascularized lymph node transfer) OR lymph node graft)). The primary outcomes were: survival of transplanted lymph node and lymphatic vessel regeneration. Sixteen studies were included. Vascularization and the use of growth factors were significantly associated with lymph node survival. Lymphatic vessels regeneration was independent from vascularization. According to the results of the current study, additional vascular anastomosis might improve the transplanted lymph node survival. Further studies in both experimental and clinical setting are needed in order to support it. J. Surg. Oncol. 2017;115:32-36. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Anouk J M Cornelissen
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Shan Shan Qiu
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Tiara Lopez Penha
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Xavier Keuter
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Stefania Tuinder
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rene van der Hulst
- Department of Plastic and Reconstructive Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
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46
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Nicoli F, Orfaniotis G, Lazzeri D, Lim SY, Kiranantawat K, Chen PY, Ciudad P, Chilgar RM, Sapountzis S, Sacak B, Chen HC. The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema. Microsurgery 2015; 36:689-694. [PMID: 26466971 DOI: 10.1002/micr.22515] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 07/28/2015] [Accepted: 09/25/2015] [Indexed: 11/11/2022]
Abstract
Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.
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Affiliation(s)
- Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Rome, Italy.,Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, St. Thomas' Hospital, London, UK
| | - Davide Lazzeri
- Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy
| | - Seong Yoon Lim
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pei-Yu Chen
- Department of Pathology, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Stamatis Sapountzis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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