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Will P, Dragu A, Zuther J, Heil J, Chang DH, Traber J, Hirche C. [Evidence of modern diagnostic, conservative, and surgical therapy of secondary lymphoedema]. HANDCHIR MIKROCHIR P 2024. [PMID: 38914123 DOI: 10.1055/a-2322-1325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Secondary lymphoedema (SL) is one of the most common and, at the same time, most significant consequences and complications of modern oncological therapy. Although a thorough patient history and physical examination are sufficient to substantiate a suspicion, it is essential to perform functional imaging of the lymphatic system for a targeted diagnosis and determination of severity. For this purpose, techniques such as MR and ICG lymphography as well as ultra-high-frequency ultrasound examinations have been developed and validated in recent years. The selective use of these techniques has allowed for individualized indications and successful stage-dependent treatment using (super)microsurgical techniques to restore regional lymphatic drainage in the context of intensified conservative therapy. METHOD Systematic review of the literature on the diagnosis and treatment of SL with subsequent analysis and classification of the results into evidence levels according to the Oxford Centre for Evidence-Based Medicine and the GRADE Scale. RESULTS The established and validated diagnosis of SL includes imaging (ICG fluorescence lymphography, MR lymphography and Tc-99 functional lymphoscintigraphy) in case of a clinical suspicion and in high-risk patients. Complex physical decongestion therapy (CPE) is superior to physical therapy or compression alone. (Super)microsurgery of SL allows for a postoperative reduction in the frequency of CPE, a reduction of erysipelas rates, a volume reduction of the lymphomatous extremity and, if carried out prophylactically, a lower incidence of SL. Suction-assited lipectomy can produce long-term, stable reductions in circumference and an improvement in quality of life. CONCLUSION Patients with SL benefit from conservative therapy with regular re-evaluation. Patients with a high risk for SL or with clinical deterioration or persistent symptoms under guideline-based conservative therapy can benefit from (super)microsurgical therapy after an individualized functional diagnostic evaluation of the lymphatic system. Excisional dermolipectomies or lympholiposuctions are available and effective for advanced and refractory stages.
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Affiliation(s)
- Patrick Will
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Adrian Dragu
- Klinik für Plastische und Handchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Joachim Zuther
- Lymphatic Unit, Academy of Lymphatic Studies, Sebastian, United States
| | - Jörg Heil
- Brustzentrum Heidelberg, St. Elisabeth Klinik, Heidelberg, Germany
| | - De-Hua Chang
- Klinik für diagnostische und interventionelle Radiologie, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Jürg Traber
- Gefäßchirurgische Klinik, Venenklinik Bellvue Kreuzlingen, Kreuzlingen, Switzerland
| | - Christoph Hirche
- Klinik für Plastische Chirurgie, Hand- und Rekonstruktive Mikrochirurgie, Handtrauma- und Replantationszentrum, BG Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany
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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 2024:101905. [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] [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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Kusajima EG, Yamamoto Y, Ishikawa K, Miura T, Funayama E, Osawa M, Takagi R, Maeda T. Sentinel node restoration by vascularized lymph node transfer in mice. Microsurgery 2024; 44:e30981. [PMID: 36321604 DOI: 10.1002/micr.30981] [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: 05/13/2022] [Revised: 09/30/2022] [Accepted: 10/21/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Recent reports have indicated that vascularized lymph node transfer (VLNT) may improve the impaired immunity in lymphedema but there has been no report concerning anti-cancer immunity. In the early tumor immune response, dendritic cells (DCs) participate in tumor recognition and antigen presentation in local lymphatics. Here, we investigated the impact of VLNT on DC dynamics against cancer in mouse models. METHODS Forty-seven 8-week-old C57BL/6 N male mice were divided into three surgical groups: a VLNT model in which a vascularized inguinal lymph node (LN) flap was transferred into the ipsilateral fossa after a popliteal LN was removed; a LN dissection (LND) model in which the popliteal LN was dissected; and a control model in which a skin incision was made at the popliteal fossa and an ipsilateral inguinal LN was removed. Postoperative lymphatic flows were observed by indocyanine green lymphography and B16-F10-luc2 mouse melanoma were implanted into the ipsilateral footpad. The proportion of DCs in the transplanted nodes was measured by CD11c immunohistochemistry using digital imaging analysis 4 days after cancer implantation. Metastases to the lungs and LNs were quantitatively evaluated by luciferase assay 4 weeks after cancer implantation. RESULTS After VLNT, lymphatic reconnection was observed in 59.2% of mice. The proportion of DCs was significantly higher in the VLNT group with lymphatic reconnection (8.6% ± 1.0%) than in the naïve LN (4.3% ± 0.4%) (p < .001). The tumor burden of lung metastases was significantly less in the VLNT group with lymphatic reconnection compared with the LND group (p = .049). CONCLUSIONS Metastasis decreased in mice with reconnected lymphatics after VLNT. A possible explanation was that lymphatic restoration may have contributed to the tumor immune response by allowing DC migration to LNs.
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Affiliation(s)
- Erika G Kusajima
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kosuke Ishikawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takahiro Miura
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Takagi
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Geyik SG, Demirdover C, Arican Alicikus LZ, Karabay N, Geyik A. Experimental Study of the Prevention and Treatment of Lymphoedema in a Rat Hindlimb Model by Applying Cardioperitoneal Catheters and Lacrimal Intubation Tubes in the Inguinoperitoneal Region. Eur J Vasc Endovasc Surg 2023; 66:587-596. [PMID: 37422208 DOI: 10.1016/j.ejvs.2023.07.001] [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: 01/05/2023] [Revised: 06/08/2023] [Accepted: 07/03/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVE Secondary lymphoedema (LE) is a chronic condition with limited surgical treatment options for restoring extremity form and function. This study aimed to establish a reproducible model of secondary LE and evaluate the preventive and corrective effects of fenestrated catheters (FC) and capillary tubes (CT). METHODS Thirty-five rats underwent left hindlimb inguinal and popliteal lymph node dissection, followed by radiotherapy after two weeks. The right hindlimb served as the control. The rats were divided into five groups: sham, two preventive (Group 2 - EFC, Group 3 - ECT), and two corrective (Group 4 - LFC, Group 5 - LCT). Measurements of ankle circumference (AC) and paw thickness (PT) were taken weekly, and imaging modalities were performed. After a 16 week follow up, rats were euthanised for histological examination. RESULTS Data include paw thickness (PT) and ankle circumference (AC) ratios for hindlimbs. In the sham group, AC ratio was 1.08 (p = .002) and PT ratio was 1.11 (p = .020), confirming successful lymphoedema model establishment. Early catheter and tube placement in Groups 2 and 3 prevented AC and PT increase until the 16th week. Group 2: the AC ratio was 0.98 (p = .93), and the PT ratio was 0.98 (p = .61). Group 3: the AC ratio was 0.98 (p = .94) and the PT ratio was 0.99 (p = .11). From the 10th to the 16th week, Groups 4 and 5 exhibited reduced measurements after insertion of catheters and tubes. Computed tomography imaging as an objective examination supported the results obtained from the measurements. The histological findings confirmed the benefits of both FC and CT. CONCLUSION The insights gained from the present study provide a basis for further exploration and refinement of drainage system designs, ultimately leading to improved treatment approaches for individuals suffering from lymphoedema in the future.
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Affiliation(s)
- Selin Guler Geyik
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | - Cenk Demirdover
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey
| | | | - Nuri Karabay
- Department of Radiology of Dokuz Eylul University, Izmir, Turkey
| | - Alper Geyik
- Department of Plastic, Reconstructive, and Aesthetic Surgery of Dokuz Eylul University, Izmir, Turkey.
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Lee JW, Lee TY, Moon KC, You HJ, Kim DW. Lymphatic complex transfer as combined lymph vessel and node transfer for advanced stage upper extremity lymphedema. J Vasc Surg Venous Lymphat Disord 2023; 11:824-831.e3. [PMID: 36906107 DOI: 10.1016/j.jvsv.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE Lymphedema, especially in the advanced stage, is a growing challenge in extremity reconstruction, with few applicable surgical methods. Despite its importance, no consensus has been reached regarding a single surgical method yet. Herein, the authors introduce a novel concept of lymphatic reconstruction yielding promising results. METHODS We included 37 patients with advanced-stage upper extremity lymphedema who underwent lymphatic complex transfers, consisting of both lymph vessel and node transfers, from 2015 to 2020. We compared the preoperative and postoperative (last visit) mean circumferences and volume ratios between the affected and unaffected limbs. Changes in the Lymphedema Life Impact Scale scores and complications were also investigated. RESULTS The circumference ratio (affected to unaffected limbs) improved at all measuring points (P < .05), while the volume ratio showed a decrease from 1.54 to 1.39 (P < .001). The mean Lymphedema Life Impact Scale decreased from 48.1 ± 15.2 to 33.4 ± 13.8 (P < .05). No donor site morbidities, including iatrogenic lymphedema or any other major complications, were observed. CONCLUSIONS A new technique for lymphatic reconstruction, lymphatic complex transfer, may be useful in cases of advanced stage lymphedema because of its effectiveness and the low possibility of donor site lymphedema.
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Affiliation(s)
- Jun Won Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Tae-Yul Lee
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyung-Chul Moon
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hi-Jin You
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Deok-Woo Kim
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, Korea.
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Banda CH, Shiraishi M, Mitsui K, Okada Y, Danno K, Ishiura R, Maemura K, Chiba C, Mizoguchi A, Imanaka-Yoshida K, Maruyama K, Narushima M. Structural and functional analysis of the newt lymphatic system. Sci Rep 2023; 13:6902. [PMID: 37106059 PMCID: PMC10140069 DOI: 10.1038/s41598-023-34169-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/25/2023] [Indexed: 04/29/2023] Open
Abstract
Regeneration competent vertebrates such as newts and salamanders possess a weakened adaptive immune system characterized by multiple connections between the lymphatic system and the blood vascular system called lymphatic hearts. The role of lymphatic vasculature and these lymphaticovenous connections in regeneration is unknown. We used in-vivo near-infrared lymphangiography, ultra-high frequency ultrasonography, micro-CT lymphangiography, and histological serial section 3-dimentional computer reconstruction to evaluate the lymphatic territories of Cynops pyrrhogaster. We used our model and supermicrosurgery to show that lymphatic hearts are not essential for lymphatic circulation and limb regeneration. Instead, newts possess a novel intraosseous network of lymphatics inside the bone expressing VEGFR-3, LYVE-1 and CD-31. However, we were unable to show Prox-1 expression by these vessels. We demonstrate that adult newt bone marrow functions as both a lymphatic drainage organ and fat reservoir. This study reveals the fundamental anatomical differences between the immune system of urodeles and mammals and provides a model for investigating lymphatics and regeneration.
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Affiliation(s)
- Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Yoshimoto Okada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Kaho Maemura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Chikafumi Chiba
- Faculty of Life and Environmental Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki Prefecture, 305-8571, Japan
| | - Akira Mizoguchi
- Department of Personalized Cancer Immunotherapy, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Kyoko Imanaka-Yoshida
- Department of Pathology and Matrix Biology, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Kazuaki Maruyama
- Department of Pathology and Matrix Biology, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, Japan.
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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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Lymphatic Tissue Transfer: Ultrasound-Guided Description and Preoperative Planning of Vascularised Lymph Nodes, Lymphatic Units, and Lymphatic Vessels Transfers. J Pers Med 2022; 12:jpm12081346. [PMID: 36013294 PMCID: PMC9410514 DOI: 10.3390/jpm12081346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The modern concept of lymphatic transfer includes vascularised lymph node transfer (VLNT), lymphatic vessels transfer (lymph interpositional flap transfer, LIFT) and lymphatic system transfer (vascularised lymph nodes and afferent lymphatics, LYST). The aim of this paper was to report our experience with different types of lymphatic transfer. Patients and Method: From June 2016 to June 2020, 30 consecutive patients affected by extremity lymphedema and 15 patients affected by post-traumatic lower extremity soft tissue defects, underwent lymphatic transfer (VLNT, LYST or LIFT). All cases were preoperatively evaluated by both high frequency and ultra-high frequency ultrasound. Flap features were recorded, as well as qualitative and quantitative outcomes at 1 year postoperative. Results: The mean postoperative lymphedema index reduction was 7.2 ± 5.7 for upper extremity and 20.7 ± 7.1 for lower extremity. No dismission of compression garments occurred, 12 patients (26%) referred more stable results of physical treatment and 1 case showed a 1-class compression reduction. All the LIFTs aimed as preventive did not develop post-traumatic lymphedema. In all cases of distal placement of VLNT and/or LYST, patients were dissatisfied with the aesthetic appearance of reconstruction, while no donor site scar disappointment was referred. Conclusion: When LVA is not feasible, LTT may represent a valid treatment option. This report was aimed at comprehensively describing and assessing how different lymphatic tissue transfer modalities may fulfil the different reconstructive needs of lymphedema patients.
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Yang CY, Tinhofer IE, Nguyen D, Cheng MH. Enhancing lymphangiogenesis and lymphatic drainage to vascularized lymph nodes with nanofibrillar collagen scaffolds. J Surg Oncol 2022; 126:1169-1175. [PMID: 35950942 DOI: 10.1002/jso.27058] [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: 05/17/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND This study investigated the effect of nanofibrillar collagen scaffold (BioBridge) implantation from the affected limb to the unaffected contralateral femoral vein or lymph node in a rat model. METHODS Hind limb lymphedema in Lewis rats was created with lymphadenectomy and inguinal circumcision without radiation. The volumetric difference (greater than 5%) using computed tomography and indocyanine green fluorescence evaluated the progress of lymphedema at 4 weeks. The lymphedema rats have separated into Group I: Controls; Group II: implanted BioBridge to the contralateral femoral vein; and Group III: implanted BioBridge to the contralateral inguinal lymph node. RESULTS A total of 14 of 30 (46.7%) rats developed hind limb lymphedema with a mean volume difference of 5.83 ± 0.99% and showed diffuse dermal backflow at 4 weeks postlymphadenectomy. Four weeks postimplantation of BioBridge, the mean volumetric difference was 5.62 ± 2.11%, 4.97 ± 0.59%, and -2.47 ± 2.37% in Group I, II, and III, respectively (p < 0.05). The dermal backflow on the affected limb increased in Groups I and II but decreased in Group III. CONCLUSIONS Implantation of BioBridge from the affected limb to the contralateral inguinal lymph node significantly reduced the hind limb lymphedema at 4 weeks.
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Affiliation(s)
- Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria
| | - Dung Nguyen
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Ming-Huei Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan.,Section of Plastic Surgery, Department of Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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Cheon H, Gelvosa MN, Kim SA, Song H, Jeon JY. Lymphatic channel sheet of polydimethylsiloxane for preventing secondary lymphedema in the rat upper limb model. Bioeng Transl Med 2022; 8:e10371. [PMID: 36684082 PMCID: PMC9842043 DOI: 10.1002/btm2.10371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/20/2022] [Accepted: 06/12/2022] [Indexed: 01/25/2023] Open
Abstract
Secondary lymphedema is a severe complication of cancer treatment, but there is no effective curative method yet. Lymph node dissection and radiation therapy for cancer treatment may lead to secondary lymphedema, which is a chronic disease induced by malfunction of lymphatic flow. The lymphatic channel sheet (LCS) is an artificial micro-fluidic structure that was fabricated with polydimethylsiloxane to maintain lymphatic flow and induce lymphangiogenesis. The structure has two-dimensional multichannels that increase the probability of lymphangiogenesis and allow for relatively easy application. We verified the efficacy of the lymphatic channel sheet through macroscopic and microscopic observation in small animal models, which underwent brachial lymph node dissection and irradiation. The lymphatic channel sheet enabled the successful transport of lymphatic fluid from the distal to the proximal area in place of the removed brachial lymph nodes. It prevented swelling and abnormal lymphatic drainage during the follow-up period. Lymphangiogenesis was also identified inside the channel by histological analysis after 8 weeks. According to these experimental results, we attest to the roles of the lymphatic channel sheet as a lymphatic pathway and scaffold in the rat upper limb model of secondary lymphedema. The lymphatic channel sheet maintained lymphatic flow after lymph node dissection and irradiation in an environment where lymph flow is cut off. It also relieved symptoms of secondary lymphedema by providing a lymph-friendly space and inducing lymphangiogenesis.
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Affiliation(s)
- Hwayeong Cheon
- Biomedical Engineering Research CenterAsan Institute for Life Sciences, Asan Medical CenterSeoulRepublic of Korea
| | - Ma. Nessa Gelvosa
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
| | - Sang Ah Kim
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
| | - Ho‐Young Song
- Department of Minimal‐Invasive InterventionThe Affiliated Cancer Hospital of Zhengzhou UniversityZhengzhou CityChina
| | - Jae Yong Jeon
- Department of Rehabilitation MedicineAsan Medical Center, University of Ulsan College of MedicineSeoulRepublic of Korea
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Francis EC, Kim BS, Lin MCY, Cheng MH. Vascularized Lymph Node Transfer Improved Outcomes of Elderly Patients with Secondary Upper Extremity Lymphedema. Ann Surg Oncol 2022; 29:7868-7878. [PMID: 35780215 DOI: 10.1245/s10434-022-12035-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 05/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Secondary lymphedema is a debilitating morbidity. This study investigated the outcomes of vascularized lymph node transfer (VLNT) in elderly patients with secondary upper extremity lymphedema. METHODS Between 2008 and 2018, elderly (≥65 years) patients with secondary upper extremity lymphedema who underwent VLNT were retrospectively reviewed. Cheng's Lymphedema Grading, Taiwan Lymphoscintigraphy Staging, and indocyanine green lymphography were used to select the procedures. Outcome measurements included complications, circumferential difference, episodes of cellulitis, and the Lymphedema-Specific Quality of Life questionnaire (LYMQoL). RESULTS Eleven patients with a mean age of 70.2 ± 5.3 years (range 65-80 years) who underwent VLNT survived and no major complications were encountered. At a mean follow-up of 6.5 ± 3.6 years (range 2-13 years), the mean limb circumferential difference was significantly improved from 25.6 ± 11.5% to 8.3 ± 4.2% (p = 0.016), and the mean episode of cellulitis was statistically reduced from 2.4 ± 1.3 to 0.4 ± 0.9 times/year (p = 0.007). At a follow-up of 24 months, four domains of Function (from 30.6 ± 2.8 to 14.5 ± 2.5), Appearance (from 18.2 ± 1.9 to 8.5 ± 2.1), Symptoms (from 30.4 ± 5.9 to 10.9 ± 1.0) and Mood (from 29.2 ± 4.4 to 10.7 ± 1.0), as well as overall LYMQoL score (from 3.9 ± 1.1 to 7.4 ± 0.5), showed statistical improvement (all p < 0.05). CONCLUSIONS VLNT for secondary upper extremity lymphedema in elderly patients significantly decreased the limb circumferential difference and frequency of cellulitis and improved quality of life without using compression garments postoperatively.
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Affiliation(s)
- Eamon C Francis
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Bong-Sung Kim
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Plastic and Hand Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Miffy Chia-Yu Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Section of Plastic Surgery, The University of Michigan, Ann Arbor, MI, USA.
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12
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Surgical treatment of lower extremity lymphedema with subcutaneous implantation of silicone tubing. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:453-457. [PMID: 36303685 PMCID: PMC9580300 DOI: 10.5606/tgkdc.dergisi.2022.22554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 01/19/2022] [Indexed: 11/21/2022]
Abstract
A 65-year-male patient was admitted to our clinic with swollen, painful, and wound discharge of lower extremity. There was widespread edema, skin infection, and lymphangitis secondary Stage 3 lymphedema below the knee. In addition to conventional treatment methods, lymphatic artificial pathway creation was used with subcutaneous implantation of silicone tubing. In conclusion, subcutaneous implantation of silicone tubing is a new technique that can be applied in advanced stage lymphedema patients, which increases the effectiveness of compression therapy.
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13
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Yang CY, Tinhofer IE, Cheng MH. Long-term outcomes of arterial ischemia or venous occlusion on vascularized groin lymph nodes in a rat model. J Surg Oncol 2022; 126:633-639. [PMID: 35678754 DOI: 10.1002/jso.26980] [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: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study investigated the long-term effects of arterial ischemia and venous occlusion on lymph node drainage function in a rat model. METHODS Bilateral groin lymph node flaps of 18 Lewis rats were dissected. The pedicle artery was clamped for 4, 5, and 6 h (A4, A5, and A6 groups), and the vein for 3, 4, and 5 h (V3, V4, and V5 groups) in six flaps. At 4 weeks, the evaluations included gross morphomics, indocyanine green (ICG) lymphography, histological section, immunofluorescence of terminal deoxynucleotidyl transferase assay, and heme oxygenase-1 (HO-1) stain. RESULTS The lymph node flaps developed shrinkage and partial necrosis in A5, A6, V4, and V5 groups. Hemorrhage in the lymph node cortex and medulla was observed histologically in A5, A6, and V5 groups. ICG lymphography showed loss of lymphatic drainage function in 2 of 6 flaps in A6 and V5 groups. Cell death was shown partly in cortical follicles in A5 and V4 groups and completely in A6 and V5 groups. The HO-1 expression was statistically increased in A5 and V5 groups, respectively (p < 0.05). CONCLUSIONS The critical arterial ischemia and venous occlusion time were 4 h at 4 weeks of follow-up.
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Affiliation(s)
- Chin-Yu Yang
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ines E Tinhofer
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of Divine Savior, Vienna, Austria
| | - Ming-Huei Cheng
- Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan
- Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Division of Plastic Surgery, Ann The University of Michigan, Arbor, Michigan, USA
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14
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Wang H, Dong D, Liu C, Yuan M, Chen L, Liu T. The Effects of Methylene Blue and Carbon Nanoparticles on Transplanted Lymph Node Survival, Reconstructed Lymphatic Function, and Changes in Inflammatory and Fibrosis Factors. World J Surg 2022; 46:2166-2173. [PMID: 35618946 DOI: 10.1007/s00268-022-06594-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Methylene blue (MB) and carbon nanoparticles (CNs) can be used as a simple method for reverse lymphatic mapping. We investigated whether the two tracers had an impact on the survival of lymph nodes and the function of reconstructed lymph vessels after transplantation, as well as the changes in surrounding related factors. METHODS The stained lymph nodes were non-vascularized transplanted into the contralateral popliteal fossa in mice. After 4 weeks, the lymphatic recanalization was detected. The samples were harvested for pathological detection and PCR. In addition, the transport ability of the recanalized lymphatics to tumor cells was also explored. RESULTS Compared with the control group, there was no significant difference of the MB and CNs groups in the drainage function of recanalized lymphatic vessels, the survival of lymph nodes, or the transport capacity to tumor cells. TNF-α and IL-6 were significantly higher in the two tracer groups (**p < 0.01). Besides, the α-SMA was significantly increased in the CNs group (*p < 0.05). CONCLUSIONS Two tracers have no effect on the survival of transplanted lymph nodes, nor do they affect the drainage ability or tumor cell capture ability of the reconstructed lymphatics, despite improving TNF-α and IL-6 levels and the deposition of CNs.
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Affiliation(s)
- Heng Wang
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Dong Dong
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Chi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Mingjie Yuan
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Shanghai, China
| | - Liang Chen
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Tianyi Liu
- Department of Plastic and Aesthetic Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China.
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15
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A meta-analysis of 37 studies on the effectiveness of microsurgical techniques for lymphedema. Ann Vasc Surg 2022; 86:440-451.e6. [PMID: 35589027 DOI: 10.1016/j.avsg.2022.04.038] [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: 12/02/2021] [Revised: 03/03/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Microsurgery is a new technique for lymphedema treatment. Its advantages and disadvantages remain controversial. This study sought to collect clinical data from patients who underwent lymphovenous bypass and vascularized lymph node transplantation to explore whether surgical procedures can effectively treat lymphedema. METHODS We performed a meta-analysis of the effectiveness of lymphatic microsurgery. We searched the databases of literature for articles in Chinese and English. These articles were graded for quality. Report details and outcomes were recorded. Data extraction, systematic review, and meta-analysis were performed. RESULTS Thirty-seven studies were included. Patients who underwent microsurgery had a significantly better chance of achieving an excellent result than patients who received conservative treatment (odds ratio=7.07). The affected limb circumference was reduced by approximately 44.68% after the microsurgery. After the microsurgery, 63% of the patients did not need physiotherapy, and 96% were free from painful skin infections. Lymphography showed that lymphatic transport capacity was enhanced. Moreover, 12% of the patients reported that edema reappeared in the long-term, 26% required reoperation for unsatisfactory results, and 32% experienced lymphatic leakage. CONCLUSIONS A vast majority of patients derive more benefit from lymphatic microsurgery than from conventional treatment. The advantages of lymphatic microsurgery outweigh the disadvantages for patients in the early and middle stages of chronic secondary lymphedema and patients in whom conventional treatment failed.
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16
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Long-Term Outcomes of Lymph Node Transfer in Secondary Lymphedema and Its Correlation with Flap Characteristics. Cancers (Basel) 2021; 13:cancers13246198. [PMID: 34944817 PMCID: PMC8699309 DOI: 10.3390/cancers13246198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This retrospective study aimed to assess the impact of certain flap characteristics on long-term outcomes following microsurgical treatment in Breast Cancer-Related Lymphedema (BCRL) patients. METHODS Sixty-four out of 65 BCRL patients, guided by the "Selected Lymph Node" ("SeLyN") technique, underwent Vascularized Lymph Node Transfer (VLNT) between 2012 and 2018. According to their surface size, flaps were divided into small (<25 cm2, n = 32) and large (>25 cm2, n = 32). Twelve large and six small flaps were combined with free abdominally based breast reconstruction procedures. Lymphedema stage, flap size, vascular pedicle and number of lymph nodes (LNs) were analyzed in correlation with long-term Volume Differential Reduction (VDR). RESULTS At 36-month follow-up, no major complication was recorded in 64 cases; one flap failure was excluded from the study. Mean flap size was 27.4 cm2, mean LNs/flap 3.3 and mean VDR 55.7%. Small and large flaps had 2.8 vs. 3.8 LNs/flap (p = 0.001), resulting in 49.6% vs. 61.8% VDR (p = 0.032), respectively. Lymphedema stage and vascular pedicle (SIEA or SCIA/SCIP) had no significant impact on VDR. CONCLUSION In our series, larger flaps included a higher number of functional LNs, directly associated with better outcomes as quantified by improved VDR.
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17
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Chocron Y, Azzi AJ, Bouhadana G, Kokosis G, Vorstenbosch J. Axilla versus Wrist as the Recipient Site in Vascularized Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review and Meta-Analysis. J Reconstr Microsurg 2021; 38:539-548. [PMID: 34875698 DOI: 10.1055/s-0041-1740132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. METHODS We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. RESULTS A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. CONCLUSION These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.
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Affiliation(s)
- Yehuda Chocron
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Alain J Azzi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
| | | | - George Kokosis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Joshua Vorstenbosch
- Division of Plastic and Reconstructive Surgery, Department of Surgery, McGill University, Montreal, Quebec, Canada
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18
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Jarvis NR, Torres RA, Avila FR, Forte AJ, Rebecca AM, Teven CM. Vascularized omental lymphatic transplant for upper extremity lymphedema: A systematic review. Cancer Rep (Hoboken) 2021; 4:e1370. [PMID: 33826249 PMCID: PMC8388172 DOI: 10.1002/cnr2.1370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Vascularized omental lymphatic transplant (VOLT) is an increasingly popular treatment of extremity lymphedema given its promising donor site. While the success of VOLT in the treatment of lymphedema has been reported previously, several questions remain. AIM To further elucidate appropriate use of VOLT in the treatment of lymphedema, specifically addressing patient selection, harvest technique, and operative methods. METHODS AND RESULTS A systematic review of VOLT for upper extremity lymphedema was performed. Of 115 yield studies, seven were included for analysis based on inclusion and exclusion criteria. Included studies demonstrated significant reductions in extremity circumference/volume (average volume reduction, 22.7%-39.5%) as well as subjective improvements using patient-reported outcomes. Though studies are heterogenous and limited, when analyzed in aggregate, suggest the efficacy of VOLT in lymphedema treatment. CONCLUSION This is the largest systematic review of VOLT to date. VOLT continues to show promise as a safe and efficacious surgical intervention for lymphedema in the upper extremity. Further studies are warranted to more definitively identify patients for whom this technique is appropriate as well as ideal harvest and inset technique.
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Affiliation(s)
| | | | | | | | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
| | - Chad M. Teven
- Division of Plastic and Reconstructive Surgery, Department of SurgeryMayo ClinicPhoenixArizonaUSA
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19
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Ward J, King I, Monroy-Iglesias M, Russell B, van Hemelrijck M, Ramsey K, Khan AA. A meta-analysis of the efficacy of vascularised lymph node transfer in reducing limb volume and cellulitis episodes in patients with cancer treatment-related lymphoedema. Eur J Cancer 2021; 151:233-244. [PMID: 34092349 DOI: 10.1016/j.ejca.2021.02.043] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 02/22/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Lymphoedema after cancer treatment is a chronic and disabling complication that presents a significant health care burden during survivorship with limited treatment options. Vascularised lymph node transfer (VLNT) can reconstruct lymphatic flow to reduce limb volumes, but limited higher-order evidence exists to support its effectiveness. AIM The aim of the study was to systematically review and meta-analyse the effectiveness of VLNT in reducing upper limb (UL) or lower limb (LL) volume and cellulitis episodes in patients with cancer treatment-related lymphoedema (CTRL). METHODS PubMed, Medline (Ovid) and Embase databases were searched between January 1974 and December 2019. Full-length articles where VLNT was the sole therapeutic procedure for CTRL, reporting volumetric limb, frequency of infection episodes and/or lymphoedema-specific quality-of-life data, were included in a random-effects meta-analysis of circumferential reduction rate (CRR). Methodological quality was assessed using STROBE/CONSORT, and a novel, lymphoedema-specific scoring tool was used to assess lymphoedema-specific methodological reporting. Sensitivity analyses on the site of VLNT harvest and recipient location were performed. RESULTS Thirty-one studies (581 patients) were eligible for inclusion. VLNT led to significant limb volume reductions in UL (above elbow pooled CRRs [CRRP] = 42.7% [95% confidence interval (CI): 36.5-48.8]; below elbow CRRP = 34.1% [95% CI: 33.0-35.1]) and LL (above knee CRRP = 46.8% [95% CI: 43.2-50.4]; below knee CRRP = 54.6% [95% CI: 39.0-70.2]) CTRL. VLNT flaps from extra-abdominal donor sites were associated with greater volume reductions (CRRP = 49.5% [95% CI: 46.5-52.5]) than those from intra-abdominal donor sites (CRRP = 39.6% [95% CI: 37.2-42.0]) and synchronous autologous breast reconstruction/VLNT flaps (CRRP = 32.7% [95% CI: 11.1-54.4]) (p < 0.05). VLNT was also found to reduce the mean number of cellulitis episodes by 2.1 episodes per year (95% CI: -2.7- -1.4) and increased lymphoedema-specific quality-of-life scores (mean difference in Lymphoedema-Specific Quality of Life (LYMQOL) "overall domain" = +4.26). CONCLUSIONS VLNT is effective in reducing excess limb volume and cellulitis episodes in both UL and LL lymphoedema after cancer treatment. However, significant heterogeneity exists in outcome reporting, and standardisation of reporting processes is recommended.
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Affiliation(s)
- Joseph Ward
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Ian King
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Maria Monroy-Iglesias
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Beth Russell
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Mieke van Hemelrijck
- Department of Translational Oncology and Urology Research, King's College London, London, UK
| | - Kelvin Ramsey
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK
| | - Aadil A Khan
- Department of Plastic Surgery, The Royal Marsden NHS Foundation Trust, London, UK.
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20
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Technical Challenges in "Micro" Lymph Node Identification during Vascularized Submental Lymph Node Flap Harvesting. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3330. [PMID: 33425628 PMCID: PMC7787339 DOI: 10.1097/gox.0000000000003330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/21/2020] [Indexed: 11/26/2022]
Abstract
Background: The outcome of autologous lymph node (LN) transfer has depended on the number of LNs in the donor site. Unknown accuracy of the LN counting method has thrown some doubts on the reliability of the previous statistics. This study aimed to assess the accuracy of naked eye (NK) and stereo microscopy (SM) as tools for LN count. Methods: In total, 40 vascularized submental LN flaps were harvested from 23 fresh cadavers. The colored polymer was injected into the external carotid arteries before the harvest. LNs in each flap were counted by NK, SM, and histology in sequential order. Results: An estimated 175 LNs were confirmed, 4.4 ± 1.8 per flap. NK sensitivity was 33.7% compared with that of SM at 63.5%. Both methods missed all micro-lymph nodes (micro-LNs), contributing to 5.1% (9 nodes) of all LNs. Non-LN structures (647 negative counts) were composed of fat lobules, salivary gland lobules, and muscle fibers. NK specificity was 98.0%, compared with that of SM at 96.1%. SM showed a higher false positive rate at 14.3%, compared with NK at 7.4%. False positive counts were located mostly in Ib sublevel. Conclusions: NK and SM are imperfect tools for LN count due to poor sensitivity. If the method needs to be applied, points of considerations are (1) undetectable micro-LNs, (2) interposition of LNs with the digastric muscle and submandibular salivary gland, (3) confusion of LNs with lobules of salivary gland supplied by glandular artery or fat lobules supplied by lobular artery.
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Frueh FS, Jelvani B, Scheuer C, Körbel C, Kim BS, Giovanoli P, Lindenblatt N, Harder Y, Ampofo E, Menger MD, Laschke MW. Short-term molecular and cellular effects of ischemia/reperfusion on vascularized lymph node flaps in rats. PLoS One 2020; 15:e0239517. [PMID: 33021999 PMCID: PMC7537894 DOI: 10.1371/journal.pone.0239517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/08/2020] [Indexed: 11/26/2022] Open
Abstract
Vascularized lymph node (VLN) transfer is an emerging strategy to re-establish lymphatic drainage in chronic lymphedema. However, the biological processes underlying lymph node integration remain elusive. This study introduces an experimental approach facilitating the analysis of short-term molecular and cellular effects of ischemia/reperfusion on VLN flaps. Lymph node flaps were dissected pedicled on the lateral thoracic vessels in 44 Lewis rats. VLN flaps were exposed to 45 or 120 minutes ischemia by in situ clamping of the vascular pedicle with subsequent reperfusion for 24 hours. Flaps not exposed to ischemia/reperfusion served as controls. Lymph nodes and the perinodal adipose tissue were separately analyzed by Western blot for the expression of lymphangiogenic and angiogenic growth factors. Moreover, morphology, microvessel density, proliferation, apoptosis and immune cell infiltration of VLN flaps were further assessed by histology and immunohistochemistry. Ischemia for 120 minutes was associated with a markedly reduced cellularity of lymph nodes but not of the perinodal adipose tissue. In line with this, ischemic lymph nodes exhibited a significantly lower microvessel density and an increased expression of VEGF-D and VEGF-A. However, VEGF-C expression was not upregulated. In contrast, analyses of the perinodal adipose tissue revealed a more subtle decrease of microvessel density, while only the expression of VEGF-D was increased. Moreover, after 120 minutes ischemia, lymph nodes but not the perinodal adipose tissue exhibited significantly higher numbers of proliferating and apoptotic cells as well as infiltrated macrophages and neutrophilic granulocytes compared with non-ischemic flaps. Taken together, lymph nodes of VLN flaps are highly susceptible to ischemia/reperfusion injury. In contrast, the perinodal adipose tissue is less prone to ischemia/reperfusion injury.
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Affiliation(s)
- Florian S. Frueh
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Bijan Jelvani
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Claudia Scheuer
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Christina Körbel
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Yves Harder
- Department of Plastic, Reconstructive and Aesthetic Surgery, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Emmanuel Ampofo
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Michael D. Menger
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
| | - Matthias W. Laschke
- Institute for Clinical and Experimental Surgery, Saarland University, Homburg, Saar, Germany
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22
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Will PA, Rafiei A, Pretze M, Gazyakan E, Ziegler B, Kneser U, Engel H, Wängler B, Kzhyshkowska J, Hirche C. Evidence of stage progression in a novel, validated fluorescence-navigated and microsurgical-assisted secondary lymphedema rodent model. PLoS One 2020; 15:e0235965. [PMID: 32701960 PMCID: PMC7377415 DOI: 10.1371/journal.pone.0235965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022] Open
Abstract
Secondary lymphedema (SL)is a frequent and devastating complication of modern oncological therapy and filarial infections. A lack of a reliable preclinical model to investigate the underlying mechanism of clinical stage progression has limited the development of new therapeutic strategies. Current first line treatment has shown to be merely symptomatic and relies on lifetime use of compression garments and decongestive physiotherapy. In this study, we present the development of a secondary lymphedema model in 35 rats using pre- and intraoperative fluorescence-guided mapping of the lymphatics and microsurgical induction. In contrast to the few models reported so far, we decided to avoid the use of radiation for lymphedema induction. It turned out, that the model is nearly free of complications and capable of generating a statistically significant limb volume increase by water displacement measurements, sustained for at least 48 days. A translational, accurate lymphatic dysfunction was visualized by a novel VIS-NIR X-ray ICG-Clearance-Capacity imaging technology. For the first-time SL stage progression was validated by characteristic histological alterations, such as subdermal mast cell infiltration, adipose tissue deposition, and fibrosis by increased skin collagen content. Immunofluorescence confocal microscopy analysis suggested that stage progression is related to the presence of a characteristic α SMA+/HSP-47+/vimentin+ fibroblast subpopulation phenotype. These findings demonstrate that the in-vivo model is a reliable and clinically relevant SL model for the development of further secondary lymphedema therapeutic strategies and the analysis of the veiled molecular mechanisms of lymphatic dysfunction.
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Affiliation(s)
- P. A. Will
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - A. Rafiei
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - M. Pretze
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - E. Gazyakan
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - B. Ziegler
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - U. Kneser
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
| | - H. Engel
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
- Ethianum Klinik Heidelberg, Heidelberg, Germany
| | - B. Wängler
- Department of Clinical Radiology and Nuclear Medicine, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - J. Kzhyshkowska
- Institute of Transfusion Medicine and Immunology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
- German Red Cross Blood Service Baden-Württemberg—Hessen, Frankfurt, Germany
| | - C. Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen, Germany
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23
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Paulus VAA, Winters H, Hummelink S, Schulten S, Ulrich DJO, Vasilic D. Submental flap for vascularized lymph node transfer; a CTA-based study on lymph node distribution. J Surg Oncol 2020; 122:1226-1231. [PMID: 32668040 PMCID: PMC7689706 DOI: 10.1002/jso.26117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/27/2020] [Indexed: 01/03/2023]
Abstract
Background Amongst various options of vascularized lymph node transfers, the submental flap has the lowest risk for iatrogenic lymphedema. The aim of this study was to gain insight into distribution, number, and size of lymph nodes along the mandible using computed tomography angiography (CTA). Methods A total of 52 CTA scans of head/neck region were evaluated retrospectively. Lymph nodes in the submental and submandibular region, related to the origin of the submental artery, were recorded using a three‐dimensional coordinate system, and standardized using an iterative closest point algorithm. Results were analyzed for gender, location, size, and number. Results The mean number and size of lymph nodes were 5.30 ± 2.00 and 5.28 ± 1.29 mm, respectively. The mean distance of the lymph nodes to the origin of the submental artery was 25.53 ± 15.27 mm. There was no significant difference between both sides when comparing size (left: 5.39 ± 1.28; right: 5.17 ± 1.34; P = .19), number (left: 5.46 ± 2.10; right: 5.17 ± 1.96; P = .49), and distance (left: 24.78 ± 12.23; right: 26.32 ± 14.73; P = .19). No significance was found between males and females concerning number (P = .60), size (P = .50), and distance (P = .06). Conclusion The variance of lymph node distribution along the mandible may warrant conducting a CTA scan to maximize the number of transferred lymph nodes and aid in flap design.
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Affiliation(s)
- Vera A A Paulus
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harm Winters
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stefan Hummelink
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sascha Schulten
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dietmar J O Ulrich
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dalibor Vasilic
- Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Plastic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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24
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Cheng M, Liu TT. Lymphedema microsurgery improved outcomes of pediatric primary extremity lymphedema. Microsurgery 2020; 40:766-775. [DOI: 10.1002/micr.30622] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 04/15/2020] [Accepted: 05/29/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Ming‐Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, College of Medicine, Chang Gung University Taoyuan Taiwan
| | - Tiffany Ting‐Fong Liu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, College of Medicine, Chang Gung University Taoyuan Taiwan
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25
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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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26
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Ciudad P, Manrique OJ, Bustos SS, Coca JJP, Chang C, Shih P, Nicoli F, Lo Torto F, Agko M, Huang TC, Maruccia M, Chen H. Comparisons in long‐term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery 2020; 40:130-136. [DOI: 10.1002/micr.30508] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 08/08/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Samyd S. Bustos
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - John J. P. Coca
- Department of Plastic, Reconstructive and Burn SurgeryArzobispo Loayza National Hospital Lima Peru
| | - Chang‐Cheng Chang
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Pin‐Keng Shih
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive SurgeryUniversity of Rome “Tor Vergata” Rome Italy
| | - Federico Lo Torto
- Sapienza Università di Roma, Policlinico Umberto I, Department of Surgery “P. Valdoni”Unit of Plastic Reconstructive and Aesthetic Surgery Rome Italy
| | - Mouchammed Agko
- Section of Plastic Surgery, Medical College of GeorgiaAugusta University Augusta Georgia
| | - Tony C.‐T. Huang
- Department of Plastic and Reconstructive SurgeryMayo Clinic Rochester Minnesota
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of Bari Bari Italy
| | - Hung‐Chi Chen
- Department of Plastic and Reconstructive SurgeryChina Medical University Taichung Taiwan
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27
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Ngo QD, Munot S, Mackie H, Czerniec S, Koelmeyer LA, Lam T, Heydon-White A, Suami H, Boyages J. Vascularized Lymph Node Transfer for Patients with Breast Cancer-Related Lymphedema Can Potentially Reduce the Burden of Ongoing Conservative Management. Lymphat Res Biol 2020; 18:357-364. [PMID: 31944882 DOI: 10.1089/lrb.2019.0048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Vascularized lymph node transfer (VLNT) microsurgery is conducted in selected specialist lymphatic programs as a surgical treatment option for breast cancer-related lymphedema (BCRL) with variation in treatment outcomes. Methods and Results: Ten patients with BCRL underwent VLNT from 2012 to 2015. Donor sites were the inguinal (n = 6) or supraclavicular fossa/neck (n = 4) regions and recipient sites were the axilla (n = 6) or elbow regions (n = 4). Outcomes included changes in limb volume and extracellular fluid ratios, postoperative garment use, number of cellulitis episodes, and self-reported symptom improvement. At a mean follow-up of 46 months from surgery (range: 28-66 months), the excess volume in the affected arm had reduced (n = 4) or remained stable (n = 1) for 5 of 10 patients (50%) (mean change: -106.4 mL, range: -515.5 to +69.6 mL). Four of these five patients had also reduced (n = 3) or discontinued (n = 1) wearing compression garments and three reported a reduction in episodes of cellulitis. The remaining five patients had an increase of over 100 mL in postoperative excess volume (mean change: 295.8 mL, range: 142.1-382.8 mL). Three of these five patients reported noncompliance with compression garments. Despite the increase in limb volume, some patients reported softness in swelling (n = 3) and better response to conservative treatment (n = 1). Conclusion: Our results warrant continuation of VLNT as a surgical treatment option for patients with BCRL and show that the burden of conservative management such as wearing garments can be reduced over time for some patients. Longer term follow-up with standardized measures across all centers is required to further investigate VLNT.
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Affiliation(s)
- Quan D Ngo
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Sonali Munot
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Helen Mackie
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia.,Mt. Wilga Rehabilitation Hospital, Hornsby, Australia
| | - Sharon Czerniec
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Louise A Koelmeyer
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Thomas Lam
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Asha Heydon-White
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Hiroo Suami
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
| | - John Boyages
- Australian Lymphoedema Education Research and Treatment (ALERT), Macquarie University Faculty of Medicine and Health Sciences, Sydney, Australia
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28
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Quantifying Lymph Nodes During Lymph Node Transplantation: The Role of Intraoperative Ultrasound. Ann Plast Surg 2019; 81:675-678. [PMID: 30113979 DOI: 10.1097/sap.0000000000001571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Quantifying lymph nodes in vascularized lymph node transfer (VLNT) has been performed using preoperative percutaneous ultrasound. The higher resolution and accuracy of intraoperative ultrasound (IOUS) over transcutaneous ultrasound has been demonstrated in the radiology literature for the identification and characterization of finer structures including hepatic lesions, pancreatic lesions, and biliary or pancreatic ducts. We hypothesize that IOUS during VLNT would be a superior method to quantify and map lymph nodes in our flaps. A prospectively collected database of patients undergoing VLNT over 3 years (October 2014 to October 2017) was reviewed. Patients who underwent IOUS during flap harvest, before pedicle ligation to simultaneously map and quantify the number of lymph nodes were included in the study. Twenty-one patients with an average age of 58.7 years and a mean BMI of 32.3 underwent VLNT with IOUS for chronic lymphedema during the study period. Extremity lymphedema was classified as Campisi IB (n = 7), IIA (n = 7), IIB (n = 5), and IIIA (n = 2). There were 14 superficial circumflex iliac artery flaps, including 4 performed concomitantly with a deep inferior epigastric perforator flap, 1 transverse cervical artery flap, and 6 omental flaps. The average number of lymph nodes transferred per IOUS was 4.3 for superficial circumflex iliac artery flaps, 4 for the transverse cervical artery flap, and 5.2 for the omental flaps. Intraoperative ultrasound allows the lymphatic surgeon to precisely map the location of lymph nodes which can guide intraoperative decision making. As there is no data correlating the number of lymph nodes transferred and outcomes after VLNT, developing a precise intraoperative quantification method is important.
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29
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Fernández Peñuela R, Casaní Arazo L, Masiá Ayala J. Outcomes in Vascularized Lymph Node Transplantation in Rabbits: A Reliable Model for Improving the Surgical Approach to Lymphedema. Lymphat Res Biol 2019; 17:413-417. [DOI: 10.1089/lrb.2018.0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Randolfo Fernández Peñuela
- Department of Plastic Surgery, Santa Creu i Sant Pau Hospital. (Universitat Autónoma de Barcelona), Barcelona, Spain
| | - Laura Casaní Arazo
- Catalan Institute of Cardiovascular Sciences, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Jaume Masiá Ayala
- Department of Plastic Surgery, Santa Creu i Sant Pau Hospital. (Universitat Autónoma de Barcelona), Barcelona, Spain
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30
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Brahma B, Yamamoto T. Breast cancer treatment-related lymphedema (BCRL): An overview of the literature and updates in microsurgery reconstructions. Eur J Surg Oncol 2019; 45:1138-1145. [DOI: 10.1016/j.ejso.2019.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 12/18/2022] Open
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31
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Di Taranto G, Chen S, Elia R, Bolletta A, Amorosi V, Sitpahul N, Chan JCY, Ribuffo D, Chen H. Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone. J Surg Oncol 2019; 121:168-174. [DOI: 10.1002/jso.25581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/09/2019] [Accepted: 05/20/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Giuseppe Di Taranto
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Plastic and Reconstructive SurgeryUmberto I University HospitalSapienza University of RomeRome Italy
| | - Shih‐Heng Chen
- Department of Plastic SurgeryChang Gung Memorial HospitalTaipei Taiwan
| | - Rossella Elia
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ TransplantationUniversity of BariBari Italy
| | - Alberto Bolletta
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Medical, Surgical, and Experimental SciencesPlastic Surgery UnitUniversity of SassariSassari Italy
| | - Vittoria Amorosi
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Plastic Surgery DepartmentSapienza University of RomeRome Italy
| | - Ngamcherd Sitpahul
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
- Department of Plastic and Maxillofacial Surgery, Faculty of Medicine, Ramathibodi HospitalMahidol UniversityBangkok Thailand
| | - Jeffrey CY Chan
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
| | - Diego Ribuffo
- Department of Plastic and Reconstructive SurgeryUmberto I University HospitalSapienza University of RomeRome Italy
| | - Hung‐Chi Chen
- Department of Plastic SurgeryChina Medical University HospitalTaichung Taiwan
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32
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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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33
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Ochoa O, Metzner M, Theoharis C, Chrysopoulo M, Pisano S, Nastala C, Ledoux P, Arishita G, Garza R, Snider T. Deep inferior epigastric lymph node basin: Analysis of novel donor site for vascularized lymph node transfer among 10 consecutive patients. Microsurgery 2018; 39:215-220. [DOI: 10.1002/micr.30372] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 07/11/2018] [Accepted: 08/07/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Oscar Ochoa
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | | | | | - Minas Chrysopoulo
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Steven Pisano
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Chet Nastala
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Peter Ledoux
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Gary Arishita
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Ramon Garza
- Plastic Reconstructive and Microsurgical Associates (PRMA) San Antonio Texas
| | - Ted Snider
- South Texas Pathology Associates San Antonio Texas
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34
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Maeda T, Hayashi T, Furukawa H, Iwasaki D, Ishikawa K, Funayama E, Murao N, Osawa M, Oyama A, Yamamoto Y. Immune-mediated antitumor effect of a transplanted lymph node. Int J Cancer 2018; 143:1224-1235. [DOI: 10.1002/ijc.31414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 02/23/2018] [Accepted: 03/13/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Taku Maeda
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Daisuke Iwasaki
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Kosuke Ishikawa
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Akihiko Oyama
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery; Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-ku; Sapporo City Hokkaido 060-8638 Japan
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35
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Maeda T, Yamamoto Y, Iwasaki D, Hayashi T, Funayama E, Oyama A, Murao N, Furukawa H. Lymphatic Reconnection and Restoration of Lymphatic Flow by Nonvascularized Lymph Node Transplantation: Real-Time Fluorescence Imaging Using Indocyanine Green and Fluorescein Isothiocyanate–Dextran. Lymphat Res Biol 2018; 16:165-173. [DOI: 10.1089/lrb.2016.0070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Taku Maeda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Daisuke Iwasaki
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Akihiko Oyama
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
| | - Hiroshi Furukawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Hokkaido at Sapporo (UHS), Sapporo City, Hokkaido, Japan
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36
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Pappalardo M, Patel K, Cheng MH. Vascularized lymph node transfer for treatment of extremity lymphedema: An overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol 2018; 117:1420-1431. [PMID: 29572824 DOI: 10.1002/jso.25034] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
As lymphatic microsurgery has become more common, vascularized lymph node transfer ascended to the forefront in many centers for the surgical management of advanced stages of lymphedema showing substantial clinical improvement. However, no consensus has been reached among experts regarding many details of the procedures, including patient selection criteria, type of treatment, donor, and recipient sites and postoperative evaluation of the outcome. Here, we will review these issues and provide the current results of this procedure.
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Affiliation(s)
- Marco Pappalardo
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Plastic and Reconstructive Surgery, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Ketan Patel
- Department of Plastic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan
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37
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Accurate Prediction of Submental Lymph Nodes Using Magnetic Resonance Imaging for Lymphedema Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1691. [PMID: 29707451 PMCID: PMC5908500 DOI: 10.1097/gox.0000000000001691] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 01/05/2018] [Indexed: 11/25/2022]
Abstract
Background: Submental lymph node transfer has proved to be an effective approach for the treatment of lymphedema. This study was to investigate the anatomy and distribution of vascularized submental lymph node (VSLN) flap using magnetic resonance imaging (MRI) and their clinical outcome. Methods: Fifteen patients who underwent 19 VSLN flap transfers for upper or lower limb lymphedema were retrospectively analyzed. The number of submental lymph nodes was compared among preoperative MRI, preoperative sonography, intraoperative finding, postoperative sonography, and postoperative computed tomography angiography. The outcome was compared between preoperatively and postoperatively. Results: All 19 VSLN flaps survived. Two hundred fifteen lymph nodes were identified in 30 submandibular regions by MRI. The mean number of submental lymph nodes on preoperative MRI was 7.2 ± 2.4, on preoperative sonography was 3.2 ± 1.1, on intraoperative finding was 3.1 ± 0.6, postoperative sonography was 4.6 ± 1.8, and postoperative CTA was 5.2 ± 1.9. Sixty-one percent of the lymph nodes were located in the central two-quarters of the line drawn from the mental protuberance to the mandibular angle. The actual harvest rate of submental lymph nodes was 72.2%. At a 12-month follow-up, mean episodes of cellulitis were improved from 2.7 ± 0.6 to 0.8 ± 0.2 (P < 0.01); mean of circumferential difference was improved 3.2 ± 0.4 cm (P < 0.03). The overall lymphedema quality-of-life was improved 4.9 ± 0.3 (P < 0.04). Conclusions: The preoperative MRI is a useful tool for the detection of mean 7.2 submental lymph nodes. Mean 72.2% of submental lymph nodes can be successfully transferred for extremity lymphedema with optimal functional recovery.
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38
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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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39
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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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40
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Tinhofer IE, Meng S, Steinbacher J, Roka-Palkovits J, Györi E, Reissig LF, Cheng MH, Weninger WJ, Tzou CH. The surgical anatomy of the vascularized lateral thoracic artery lymph node flap-A cadaver study. J Surg Oncol 2017; 116:1062-1068. [PMID: 28782246 DOI: 10.1002/jso.24783] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/03/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND One promising surgical treatment of lymphedema is the VLNT. Lymph nodes can be harvested from different locations; inguinal, axillary, and supraclavicular ones are used most often. The aim of our study was to assess the surgical anatomy of the lateral thoracic artery lymph node flap. MATERIALS AND METHODS In total, 16 lymph node flaps from nine cadavers were dissected. Flap markings were made between the anterior and posterior axillary line in dimensions of 10 × 5 cm. Axillary lymph nodes were analyzed using high-resolution ultrasound and morphologically via dissection. The cutaneous vascular territory of the lateral thoracic artery was highlighted via dye injections, the pedicle recorded by length, and diameter and its location in a specific coordinate system. RESULTS On average, 3.10 ± 1.6 lymph nodes were counted per flap via ultrasound. Macroscopic inspection showed on average 13.40 ± 3.13. Their mean dimensions were 3.76 ± 1.19 mm in width and 7.12 ± 0.98 mm in length by ultrasonography, and 3.83 ± 2.14 mm and 6.30 ± 4.43 mm via dissection. The external diameter of the lateral thoracic artery averaged 2.2 ± 0.40 mm with a mean pedicle length of 3.6 ± 0.82 cm. 87.5% of the specimens had a skin paddle. CONCLUSIONS The lateral thoracic artery-based lymph node flap proved to be a suitable alternative to other VLNT donor sites.
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Affiliation(s)
- Ines E Tinhofer
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Stefan Meng
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria.,Department of Radiology, Hospital Kaiser-Franz-Josef, Vienna Hospital Association, Vienna, Austria
| | - Johannes Steinbacher
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Julia Roka-Palkovits
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Eva Györi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Ming-Huei Cheng
- Division of Plastic Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial University Hospital Taipei, Taipei, Taiwan
| | - Wolfgang J Weninger
- Department of Anatomy, Medical University of Vienna, Centre for Anatomy and Cell Biology, Vienna, Austria
| | - Chieh Han Tzou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
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41
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Zeltzer AA, Anzarut A, Braeckmans D, Seidenstuecker K, Hendrickx B, Van Hedent E, Hamdi M. The vascularized groin lymph node flap (VGLN): Anatomical study and flap planning using multi-detector CT scanner. The golden triangle for flap harvesting. J Surg Oncol 2017; 116:378-383. [DOI: 10.1002/jso.24682] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/24/2017] [Indexed: 11/07/2022]
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42
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Ciudad P, Manrique OJ, Date S, Agko M, Perez Coca JJ, Chang WL, Lo Torto F, Nicoli F, Maruccia M, López Mendoza J, Chen HC. Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema. Microsurgery 2017; 37:771-779. [PMID: 28334445 DOI: 10.1002/micr.30168] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/24/2017] [Accepted: 02/28/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Biological Science and Technology; China Medical University; Taichung Taiwan
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery; Mayo Clinic; Rochester Minnesota
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - John Jaime Perez Coca
- Institute of Biotechnology, National Chung Hsing University; Taichung Taiwan, Republic of China
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michelle Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Javier López Mendoza
- Hand and Microsurgery Clinic, Hospital Ángeles del Pedregal Ciudad de México; México
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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43
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Ooi ASH, Chang DW. 5-step harvest of supraclavicular lymph nodes as vascularized free tissue transfer for treatment of lymphedema. J Surg Oncol 2017; 115:63-67. [PMID: 28114742 DOI: 10.1002/jso.24343] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 06/14/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Adrian S H Ooi
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - David W Chang
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
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44
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Poccia I, Lin CY, Cheng MH. Platysma-sparing vascularized submental lymph node flap transfer for extremity lymphedema. J Surg Oncol 2017; 115:48-53. [DOI: 10.1002/jso.24350] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Igor Poccia
- Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Chia-Yu Lin
- Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; College of Medicine; Chang Gung University; Taoyuan Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; College of Medicine; Chang Gung University; Taoyuan Taiwan
- Center for Tissue Engineering; Chang Gung Memorial Hospital; Taoyuan Taiwan
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45
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Gentileschi S, Servillo M, Garganese G, Fragomeni S, De Bonis F, Cina A, Scambia G, Salgarello M. The lymphatic superficial circumflex iliac vessels deep branch perforator flap: A new preventive approach to lower limb lymphedema after groin dissection-preliminary evidence. Microsurgery 2016; 37:564-573. [DOI: 10.1002/micr.30142] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 11/10/2016] [Accepted: 12/02/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Stefano Gentileschi
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart - Policlinico Agostino 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
| | - Giorgia Garganese
- Department of Gynecology; Catholic University Sacred Heart - Policlinico Agostino Gemelli; Largo Agostino Gemelli 1, Rome 00168 Italy
| | - Simona Fragomeni
- Department of Gynecology; 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
| | - Alessandro Cina
- Department of Radiology; Catholic University Sacred Heart - Policlinico Agostino Gemelli; Largo Agostino Gemelli 1, Rome 00168 Italy
| | - Giovanni Scambia
- Department of Gynecology; Catholic University Sacred Heart - Policlinico Agostino Gemelli; Largo Agostino Gemelli 1, 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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46
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Miranda Garcés M, Pons G, Mirapeix R, Masià J. Intratissue lymphovenous communications in the mechanism of action of vascularized lymph node transfer. J Surg Oncol 2016; 115:27-31. [PMID: 27885675 DOI: 10.1002/jso.24413] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Accepted: 08/08/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Vascularized lymph node transfer (VLNT) as a surgical treatment for cancer-related lymphedema has shown beneficial effects. The mechanism of action of this procedure involves lymphangiogenesis and lymphovenous communications (LVC) within the lymph nodes. We propose intratissue LVC as an additional element responsible for drainage of lymph to blood in the flap and examine this hypothesis in the current study. METHODS This prospective study determined the passage of lymph to the venous system via intratissue LVC in 26 free flaps used for breast reconstruction. We evaluated whether fluorescence was positive in the pedicle vein after increasing time intervals following intradermal injection of indocyanine green (ICG) dye into the flaps using near infra-red fluorescence lymphography. RESULTS We studied 26 free flaps, 22 deep inferior epigastric perforator (DIEP) flaps (84.6%), and 4 superior gluteal artery perforator (SGAP) flaps (15.4%). Fluorescence in the pedicle vein was positive in 22 of the 26 flaps (P = 0.000). The median time for fluorescence evaluation in the pedicle vein was 120 min. CONCLUSIONS Fluorescence in the pedicle vein after ICG intradermal injection indicates functional intratissue LVC in free flaps. J. Surg. Oncol. 2017;115:27-31. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- María Miranda Garcés
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau/Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Gemma Pons
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau/Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Rosa Mirapeix
- Department of Anatomy and Embriology, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Jaume Masià
- Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau/Universitat Autonoma de Barcelona, Barcelona, Spain
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47
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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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48
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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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49
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Doscher ME, Schreiber JE, Weichman KE, Garfein ES. Update on Post-mastectomy Lymphedema Management. Breast J 2016; 22:553-60. [DOI: 10.1111/tbj.12625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew E. Doscher
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Jillian E. Schreiber
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Katie E. Weichman
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
| | - Evan S. Garfein
- Division of Plastic and Reconstructive Surgery; Montefiore Medical Center; Albert Einstein College of Medicine; Bronx New York
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50
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Moltó García R, Salmerón-González E, Argudo Pechuan MD, Pérez-García A, Ripoll Orts F. Breast Cancer Recurrence in an Axillary Limphadenectomized Patient Who Underwent Lymph Node Transfer in the Axillar Region: What to Do with the Axilla? Breast J 2016; 22:588-9. [PMID: 27346452 DOI: 10.1111/tbj.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Roberto Moltó García
- Department of Plastic and Reconstructive Surgery, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Enrique Salmerón-González
- Department of Plastic and Reconstructive Surgery, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Maria D Argudo Pechuan
- Department of Breast Functional Patology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Alberto Pérez-García
- Department of Plastic and Reconstructive Surgery, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Francisco Ripoll Orts
- Department of Breast Functional Patology, University and Polytechnic Hospital La Fe, Valencia, Spain
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