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Caretto AA, Tartaglione G, Ieria FP, Colavincenzo C, Gentileschi S. Concordance between preoperative imaging methods in patients with limb lymphedema undergoing supermicrosurgical lymphaticovenular anastomosis. J Vasc Surg Venous Lymphat Disord 2024:101891. [PMID: 38631506 DOI: 10.1016/j.jvsv.2024.101891] [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: 12/05/2023] [Revised: 03/01/2024] [Accepted: 04/04/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVE Supermicrosurgical lymphaticovenular anastomosis (LVA) is increasingly being recognized as a first-line treatment of limb lymphedema because it is minimally invasive and highly effective. Lymphoscintigraphy and indocyanine green (ICG) lymphography are the two most commonly performed diagnostic imaging examinations to establish the indication and plan the procedure for patients affected by limb lymphedema. In a small group of patients, the information between these two imaging tools can be discordant, showing different anatomical drainage pathways or the absence of drainage and dermal backflow in one examination and valid drainage pathways in the other. The purpose of this study is to examine the types of possible discrepancies between lymphoscintigraphy of the superficial system and ICG lymphography and to describe the surgical outcomes after LVA for patients presenting with such discrepancies. METHODS We retrospectively reviewed the data of all patients who underwent LVA for upper or lower limb lymphedema between July 2015 and July 2023. From this series, we identified a group of patients with nonconcordant imaging results from lymphoscintigraphy and ICG lymphography before lymphatic surgery. Nonconcordant findings were described in terms of "pattern discordance" and "pathway discordance." The surgical outcome was measured by the change in the mean circumference of the limb after surgery. The changes between the preoperative and postoperative limb measures were analyzed using the Student t test. P values < .05 were considered significant. RESULTS A total of 28 patients with limb lymphedema exhibited inconsistencies between preoperative lymphoscintigraphy of the superficial system and ICG lymphography. Among these patients, 14 experienced pattern discordance, 13 had pathway discordance, and 1 patient had both. After LVA, we observed a significant reduction in the average circumference of the affected limb in the analyzed group. CONCLUSIONS The discrepancy in the information between lymphoscintigraphy and ICG lymphography in the preoperative study of patients affected by limb lymphedema is rare but possible. This phenomenon is still not fully explained; however, our results suggest that it does not correlate with the outcome of supermicrosurgical LVAs.
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Affiliation(s)
- Anna Amelia Caretto
- Unità di Chirurgia Plastica, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Chiara Colavincenzo
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Stefano Gentileschi
- Unità di Chirurgia Plastica, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
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Zhu J, Zhao F, Li F. A Retrospective Analysis of Upper Arm Rejuvenation Surgery in 50 Patients. Aesthet Surg J 2024; 44:NP254-NP262. [PMID: 38114083 DOI: 10.1093/asj/sjad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/01/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Upper arm aesthetics often suffer from aging effects such as skin laxity and sagging due to collagen and elastin depletion. Fat loss, obesity, and weight fluctuations further exacerbate these issues. Existing classification systems for upper arm excess are complex and have practical limitations. OBJECTIVES The aim of this study was to develop a more concise and clearer classification of upper arm excess that can guide surgical interventions effectively and assess clinical outcomes. METHODS Patients undergoing upper arm rejuvenation surgery from January 2020 to January 2023 were categorized as mild, moderate, or severe. Mild cases underwent suction-assisted liposuction (SAL), moderate cases underwent radiofrequency-assisted liposuction combined with SAL, and severe cases underwent brachioplasty combined with SAL. Arm circumferences and BODY-Q questionnaires were collected pre- and postoperatively. RESULTS The study included 50 female patients, aged 21 to 49 years. The average follow-up time was 7.5 [2.2] months. Arm circumference reduction rates were 6.8% in mild cases, 15.1% in moderate cases, and 17.3% in severe cases. Regarding the BODY-Q questionnaire for upper arms, the average score increased by 0.9 for mild, 2.1 for moderate, and 2.9 for severe cases. Complications were minimal, including 1 seroma and 2 cases of scar widening. CONCLUSIONS The revised classification system for upper arm excess proved effective in guiding surgical decisions. Selecting the surgical approach based on severity resulted in satisfactory outcomes based on BODY-Q scores. This system offers a concise, objective, and practical tool for plastic surgeons. LEVEL OF EVIDENCE: 3
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Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58050631. [PMID: 35630048 PMCID: PMC9143574 DOI: 10.3390/medicina58050631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.
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Bianchi A, Salgarello M, Visconti G. Lipobrachiopexy: Cosmetic Outcomes and Limb Lymphatic Function of a Novel Brachioplasty Technique in Massive Weight Loss Patients. Aesthetic Plast Surg 2022; 46:786-794. [PMID: 34623460 DOI: 10.1007/s00266-021-02583-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Many types of brachioplasty techniques have been described in the literature, and the main focus has been scar aesthetics, reproducibility and safety. Little attention has been given to other two aspects of the procedure: overall aesthetic with a focus on the torso-brachial angle and on the lymphatic distress related to the procedure. In this paper, we described a novel technique of brachioplasty called lipobrachiopexy, a lymph-sparing procedure which includes tendon suspension suture to improve cosmetics . PATIENTS AND METHODS Over 18 months, 22 consecutive patients underwent bilateral lipobrachioplasty with circumferential liposuction sparing brachial artery perforators, J-scar dermolipectomy and superficial fascia suspension to the pectoralis major tendon. Aesthetic outcomes, lymphatic function, sensory function and patient's satisfaction were evaluated at 1-year follow-up. The correction of the bat wing deformity and the shape of the transition of the upper arm to the chest was evaluated by quantifying the torso-brachial angle using Photoshop. Lymphatic function was analysed pre-operatively at 1, 6 and 12 months after surgery by indocyanine green lymphography (PDE, Hamamatsu Photonics, Japan). RESULTS An average of 447.5 cc (range, 350-550 cc) of fat was aspirated for each side. No major complications were experienced. Patients' and surgeons' satisfaction was high to very high in all cases. The lymphatic function was found preserved, with the same physiological linear patterns and tracer progression pre-operatively and 1 year after surgery. The torso-brachial angles showed significant improvements (86.7 ± 14.7-100.7 ± 10.2 right side and 85.4 ± 16.3-101.5 ± 9.9 left side). CONCLUSION Lipobrachiopexy is a safe and effective technique that adds to the recent trends in brachioplasty, a reestablishment of the brachial fascial systems and addressing the anatomical etiological factor of the bat wing deformity. LEVEL OF EVIDENCE 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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Aljerian A, Abi-Rafeh J, Ramirez-GarciaLuna J, Hemmerling T, Gilardino MS. Complications in Brachioplasty: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2022; 149:83-95. [PMID: 34936607 DOI: 10.1097/prs.0000000000008652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Brachioplasty procedures have experienced a surge in popularity over the past decade, mirroring the rise in bariatric procedures and growing population of massive weight loss patients. The authors estimated the incidence of associated complications and identify possible patient- or procedure-related predictive factors. METHODS A systematic review was performed using the PubMed, Cochrane, and Embase databases; extracted data were synthesized through a random-effects meta-analysis of proportions and a multivariate meta-regression. RESULTS Twenty-nine studies were included in the meta-analysis, representing 1578 patients; all studies followed an observational design. The incidence of adverse outcomes assessed included aberrant scarring, 9.9 percent (95 percent CI, 6.1 to 15.6 percent); ptosis or recurrence, 7.79 percent (95 percent CI, 4.8 to 12.35 percent); wound dehiscence, 6.81 percent (95 percent CI, 4.63 to 9.90 percent); seroma, 5.91 percent (95 percent CI, 3.75 to 9.25 percent); infection, 3.64 percent (95 percent CI, 2.38 to 5.53 percent); nerve-related complications, 2.47 percent (95 percent CI, 1.45 to 4.18 percent); lymphedema or lymphocele formation, 2.46 percent (95 percent CI, 1.55 to 3.88 percent); skin necrosis or delayed healing, 2.27 percent (95 percent CI, 1.37 to 3.74 percent); and hematoma, 2.06 percent (95 percent CI, 1.38 to 3.06 percent). The operative reintervention rate for aesthetic purposes was 7.46 percent (95 percent CI, 5.05 to 10.88 percent), and the operative reintervention rate for nonaesthetic purposes was 1.62 percent (95 percent CI, 1.00 to 2.61 percent). Multivariate meta-regression demonstrated that medial incision placement was associated with a higher risk of complications, whereas the incidence of certain complications was lowered with adjunctive liposuction (p < 0.05). CONCLUSION In the absence of large clinical trials, the present meta-analysis can serve to provide plastic surgeons with an evidence-based reference to improve informed consent and guide procedure selection with respect to the complication profile of brachioplasty.
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Affiliation(s)
- Albaraa Aljerian
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center; and Division of Experimental Surgery, Faculty of Medicine, and Department of Anesthesia, McGill University
| | - Jad Abi-Rafeh
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center; and Division of Experimental Surgery, Faculty of Medicine, and Department of Anesthesia, McGill University
| | - José Ramirez-GarciaLuna
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center; and Division of Experimental Surgery, Faculty of Medicine, and Department of Anesthesia, McGill University
| | - Thomas Hemmerling
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center; and Division of Experimental Surgery, Faculty of Medicine, and Department of Anesthesia, McGill University
| | - Mirko S Gilardino
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Center; and Division of Experimental Surgery, Faculty of Medicine, and Department of Anesthesia, McGill University
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Elgazzar K, Hassan AA. Autoaugmentation Brachioplasty: An Arm Contouring Method in Women with Massive Weight Loss. Aesthetic Plast Surg 2021; 45:2233-2241. [PMID: 33580276 DOI: 10.1007/s00266-021-02138-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Brachioplasty of deflated arms following massive weight loss (MWL) often results in too slim arms. These slimmer arms lack the natural proportion and contour. This study presents a novel method for such arms through standard skin excision and autoaugmentation by dermofat flap. PATIENTS During a period of 2 years, 21 women complaining of severe deflation deformity of upper arms following MWL were operated. At time of surgery, the BMI ranged from 20.5 to 33. 4 with a mean of 26.2 kg/m2. The mean value of weight loss was 47.8 kg over a mean period of 18 months. METHODS A de-epithelialized dermofat flap was preserved underneath the dissected and advanced anterior and posterior arm skin flaps. The bulk of the flap was tailored as to give an appropriate girth with balanced proportion and contour of the upper arm. RESULTS During 14 months of follow-up, all patients reported a high satisfaction. Objective evaluation was based on measurement of the mid-upper arm circumferences (MUAC) and its ratio with the mid-forearm circumferences (MFAC) which was compared with those of arms of healthy volunteers with normal BMIs. CONCLUSION Augmentation of the upper arm by autologous dermofat flap provides a well arm contour in appropriate balance with the forearm in women having severe arm deflation deformity following MWL. The findings were supported by the objective anthropometric measurements of the MUAC/MFAC of a normal weight healthy women which reached to a mean value of 1.366. The normal girth of upper arm should equal 1[Formula: see text] that of the forearm. LEVEL OF EVIDENCE 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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Risk factors for late-onset lower limb lymphedema after gynecological cancer treatment: A multi-institutional retrospective study. Eur J Surg Oncol 2020; 46:1334-1338. [PMID: 32146054 DOI: 10.1016/j.ejso.2020.01.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/19/2020] [Accepted: 01/28/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Late-onset lower limb lymphedema (LLL) is a significant clinical challenge for physicians dealing with patients that undergo treatment involving the pelvic cavity. We aimed to clarify the prevalence of and risk factors for late-onset LLL after treatment for gynecological cancer. METHODS We conducted a multicenter retrospective study using records of cases in which LLL diagnosed by physical findings and measurement of limbs girths. Patients with LLL after treatment for uterine cervical, endometrial, and ovarian cancer were sequentially enrolled. We examined the timing of LLL onset and the associations between the time to onset and clinical characteristics, including age, type of cancer, lymphadenectomy sites, and performance of radiotherapy. We also investigated the risk factors for late-onset LLL and their effects on the cumulative incidence of late-onset LLL. RESULTS In total, 711 patients fulfilled the required criteria. Mean age of was 50.2 years old and median follow-up period was 5.05 years. More than half of them (50.5%) presented with LLL ≥5 years after undergoing treatment for gynecological cancer. A substantial number of patients (29.4%) developed LLL ≥10 years after undergoing treatment for gynecological cancer. Being aged <50 years [(odds ratio (OR): 1.919, P = 0.001), cervical cancer (OR: 1.912, P = 0.001), and radiotherapy (OR: 1.664, P = 0.017) were identified as significant risk factors for late-onset LLL in multivariate logistic regression analysis. CONCLUSIONS A substantial number of patients present with LLL ≥5 years after receiving treatment for gynecological malignancies. Clinicians are required to identify high-risk patients and inform them of the risk of late-onset LLL.
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Ezawa M, Sasaki H, Yamada K, Takano H, Iwasaka T, Nakao Y, Yokochi T, Okamoto A. Long term outcomes from lymphatic venous anastomosis after total hysterectomy to prevent postoperative lymphedema in lower limb. BMC Surg 2019; 19:177. [PMID: 31771562 PMCID: PMC6878618 DOI: 10.1186/s12893-019-0628-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Lymphedema in lower limb is one of major postoperative complications followed by a total hysterectomy with lymph node dissection. The objective of this report is to examine a long-term result of lymphaticovenous anastomosis procedure as a preventive surgery. METHODS Sixteen patients with endometrial cancer underwent an abdominal hysterectomy with a bilateral salpingo-oophorectomy. Just after pelvic lymph node dissection, either end-to-end or sleeve anastomosis utilizing venules and suprainguinal lymph vessels was performed. During the observation period from 4 to 13 years, the symptom of lymphedema in lower extremities has been assessed. RESULTS Among 16 patients, 1 presented postoperative lymphedema grade 3 (CTCAE (Common Terminology Criteria for Adverse Events) Ver. 4.0, 10025233) in lower limb, and a second surgery at 7 years after the first one was required. Other 6 patients showed non-severe symptoms of lymphedema, diagnosed as grade 1. The rest 9 patients did not show any symptoms of postoperative lymphedema in a long term (up to 13 years). CONCLUSION From the long term outcomes of our 16 cases, we propose that a direct lymphaticovenous microsurgery immediately after a hysterectomy with lymphadenectomy of external inguinal lymph node is one of the appropriate therapeutic choices to prevent severe lymphedema in lower limb.
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Affiliation(s)
- Masahiro Ezawa
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroshi Sasaki
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan. .,Department of Gynecology, Chiba Tokushukai Hospital, Chiba, Japan.
| | - Kyosuke Yamada
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirokuni Takano
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Tsuyoshi Iwasaka
- Department of Obstetrics and Gynecology, Saga University School of Medicine, Saga, Japan
| | | | - Tomoki Yokochi
- Department of Clinical Research, Chiba Tokushukai Hospital, Chiba, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
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Gentileschi S, Albanese R, Pino V, Stefanizzi G, Fragomeni S, Zagaria L, Ieria FP, Salgarello M, Scambia G, Garganese G. SPECT/CT and fusion ultrasound to target the efferent groin lymph node for lymphatic surgery. Microsurgery 2019; 39:605-612. [PMID: 31400162 DOI: 10.1002/micr.30501] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/19/2019] [Accepted: 07/29/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Pelvic lymphadenectomy (PL) causes changes to the inguinal lymph nodes with progressive loss of immune and lymphatic pump function. Efferent lymphatic vessel-to-venous anastomosis (ELVA) has been reported to address this problem. The aim of this report was to describe the feasibility of the SPECT/CT combined with ultrasound fusion imaging (UFI) to target the groin efferent lymph node (GELN) for ELVA. PATIENTS AND METHODS Twelve patients with lower limb lymphedema after PL were scheduled for peripheric lymphaticovenular anastomosis (LVA) combined with ELVA. All-patients were clinically ISL-stage1, with good visualization of the inguinal lymph nodes at preoperative lymphoscintigraphy. The mean patient age was 55.4 years and the mean BMI was 25.5.The mean limb circumference (MLC) was calculated before surgery and 1 year after surgery. The LymQoL-Leg questionnaire was administered before surgery and 6 months after surgery. Before surgery, the GELN was identified by SPECT/CT and its location was marked on the skin by UFI virtual navigation. Peripheric LVA sites were planned by ultrasound and indocyanine green (ICG) lymphography. Pre and postoperative MLC and LymQoL-Leg scores were compared. RESULTS In all-patients, the SPECT/CT succeeded at detecting and targeting the GELN. In all-patients, real-time anatomical coregistration with US was feasible, and it was possible to mark on the groin skin the depth and position of the GELN on the skin at the groin. During surgery, in every patient, we found the GELN marked before surgery and performed ELVA. We also performed two or three peripheric LVAs in every patient. The mean value of MLC decreased (38.2 ± 2.13 cm vs. 36.33 ± 2.14 cm; p = .04) and the mean score of the LymQoL-Leg questionnaire improved (9.3 ± 1.7 vs. 7.7 ± 1.1; p = .02). CONCLUSION SPECT/CT combined with UFI is feasible for the preoperative identification of GELN for ELVA.
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Affiliation(s)
- Stefano Gentileschi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Unità di Chirurgia Plastica, Roma, Italy.,Università Cattolica del Sacro Cuore, Istituto di Clinica Chirurgica, Roma, Italy
| | - Roberta Albanese
- Università Cattolica del Sacro Cuore, Istituto di Clinica Chirurgica, Roma, Italy
| | - Valentina Pino
- Università Cattolica del Sacro Cuore, Istituto di Clinica Chirurgica, Roma, Italy
| | - Gianluigi Stefanizzi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Unità di Chirurgia Plastica, Roma, Italy
| | - Simona Fragomeni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Roma, Italy
| | - Luca Zagaria
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Diagnostica per Immagini Radioterapia oncologica ed Ematologia, Roma, Italy
| | | | - Marzia Salgarello
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Unità di Chirurgia Plastica, Roma, Italy.,Università Cattolica del Sacro Cuore, Istituto di Clinica Chirurgica, Roma, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Roma, Italy.,Università Cattolica del Sacro Cuore, Istituto di Clinica Ostetrica e Ginecologica, Roma, Italy
| | - Giorgia Garganese
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Dipartimento Scienze Della Salute Della Donna E Del Bambino E Di Sanità Pubblica, Roma, Italy.,Gynecology and Breast Care Center, Mater Olbia Hospital, Olbia, Italy
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Myers PL, Bossert RP. Arm Contouring in the Massive-Weight-Loss Patient. Clin Plast Surg 2018; 46:85-90. [PMID: 30447832 DOI: 10.1016/j.cps.2018.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Brachioplasty is an increasingly popular procedure performed for improved arm contour in the massive-weight-loss population. There are challenging deformities presented in this population, such as redundant skin, posterior arm lipodystrophy, and loosening of fascial layers of the upper arm and chest wall that must be addressed to achieve successful contour of the arms. Common complications can be minimized with meticulous technique and knowledge of surgical anatomy. Additionally, brachioplasty can be combined with liposuction of the posterior arm as a safe and effective method for arm contouring without a higher risk of complications.
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Affiliation(s)
- Paige L Myers
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 661, Rochester, NY 14642, USA
| | - Ronald P Bossert
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 661, Rochester, NY 14642, USA.
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Abstract
Arm contour improvement is a desired goal of the massive weight loss and the aging population who want to maintain the arm aesthetics. Brachioplasty is a growing and safe procedure to improve the arm contour and different approaches and innovative treatment options have been described since the 1930s. This paper reviews the relevant literature in arm contouring including surgical and nonsurgical procedures used to aesthetically improve the arm. A comprehensive literature review was performed using the words "brachioplasty," "arm lift," "arm contouring," "arm liposuction," "noninvasive arm lift," "minimally invasive arm lift." Commonly used techniques, classification systems, and procedure outcomes are described. The review demonstrated that there are several methods to accomplish good arm contouring. There is no consensus about the best incision type and location, but the classification systems help guide treatment. Assessment of fat excess, skin excess, and location of the deformity (proximal, entire arm, arm and chest) help determine the best approach including liposuction only, skin resection only, a combination of liposuction and excision, or even the use of nonsurgical devices. Infection, hematoma, and unsatisfactory scars are the most commonly reported complications. Brachioplasty is a growing procedure and can be performed with low complication rates and good patient satisfaction. Classification systems stratify deformities to the ideal treatment but no studies have shown the superiority of any technique. Nonsurgical fat removal and skin tightening of the arms are promising procedures for selected patients and higher levels of evidence are needed to show clear indication for different technologies and devices.
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Affiliation(s)
- Gabriele Miotto
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA
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Gentileschi S, Servillo M, Albanese R, De Bonis F, Tartaglione G, Salgarello M. Lymphatic mapping of the upper limb with lymphedema before lymphatic supermicrosurgery by mirroring of the healthy limb. Microsurgery 2017; 37:881-889. [PMID: 28952193 DOI: 10.1002/micr.30247] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 08/28/2017] [Accepted: 09/05/2017] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Supermicrosurgical lymphatic-venous anastomosis (LVA) can improve limbs lymphedema. We describe a technique that we employ for preoperative lymphatic mapping of the upper limb (UL), when indocyanine green (ICG) lymphography shows only dermal backflow (DB) and no lymphatic vessel is detectable. PATIENTS AND METHODS Sixteen patients undergoing LVA for unilateral UL lymphedema, showing "stardust" or "diffuse" DB pattern, were included. Demographic, clinical data, and limbs measurements were recorded. LymQoL arm questionnaire was administered. Mean age of patients was 58.8 ± 13.1 years. Fifteen were females and 1 male. Lymphatic anatomy of the healthy limb was investigated by ICG lymphography and reported on the affected limb by a four steps technique: marking the main lymphatic pathway on the healthy limb, measuring of the distances at seven levels between the pathway and a line joining fixed landmarks, reporting these measurements on the affected limb with a correction proportional to the degree of swelling, marking skin incisions at the intersection of this pathway with venules, individuated by near infrared light system. Results were analyzed by postoperative questionnaire and changes of limb measurements. RESULTS For every limb, we could find 3 ± 0.73 incision sites each containing at least one lymphatic vessel suitable for anastomosis. In every patient, we could perform 3.38 ± 0.62 anastomoses. Mean follow-up was 12.13 ± 2.73 months. After surgery, mean preoperative QoL score increased from 5.5 to 7.9 (P < .001), and mean difference between the mean circumferences of the affected and healthy limbs decreased from 4.3 ± 1.3 to 2.5 ± 1.3 cm, showing improvement of swelling after surgery (P < .01). CONCLUSION This technique allowed to preoperatively map UL lymphatics even if diffuse DB was present.
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Affiliation(s)
- Stefano Gentileschi
- Department of Plastic and Reconstructive Surgery, Fondazione Policlinico Universitario A. Gemelli, Largo Agostino Gemelli 1, Rome 00168, Italy
| | - Maria Servillo
- Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart, Policlinico Agostino Gemelli, Largo Agostino Gemelli 1, Rome 00168, Italy
| | - Roberta Albanese
- Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart, Policlinico Agostino Gemelli, Largo Agostino Gemelli 1, Rome 00168, Italy
| | - Francesca De Bonis
- Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart, Policlinico Agostino Gemelli, Largo Agostino Gemelli 1, Rome 00168, Italy
| | - Girolamo Tartaglione
- Department of Nuclear Medicine, Ospedale Cristo Re, Via delle Calasanziane 25, Rome 00168, Italy
| | - Marzia Salgarello
- Department of Plastic and Reconstructive Surgery, Catholic University Sacred Heart, Policlinico Agostino Gemelli, Largo Agostino Gemelli 1, Rome 00168, Italy
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