1
|
Gaxiola-García MA, Escandón JM, Manrique OJ, Skinner KA, Kushida-Contreras BH. Surgical Treatment for Primary Lymphedema: A Systematic Review of the Literature. Arch Plast Surg 2024; 51:212-233. [PMID: 38596145 PMCID: PMC11001464 DOI: 10.1055/a-2253-9859] [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: 09/14/2023] [Accepted: 11/30/2023] [Indexed: 04/11/2024] Open
Abstract
This is a retrospective review of surgical management for primary lymphedema. Data were extracted from 55 articles from PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Central Register of Controlled Trials between the database inception and December 2022 to evaluate the outcomes of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), and outcomes of soft tissue extirpative procedures such as suction-assisted lipectomy (SAL) and extensive soft tissue excision. Data from 485 patients were compiled; these were treated with LVA ( n = 177), VLNT ( n = 82), SAL ( n = 102), and excisional procedures ( n = 124). Improvement of the lower extremity lymphedema index, the quality of life (QoL), and lymphedema symptoms were reported in most studies. LVA and VLNT led to symptomatic relief and improved QoL, reaching up to 90 and 61% average circumference reduction, respectively. Cellulitis reduction was reported in 25 and 40% of LVA and VLNT papers, respectively. The extirpative procedures, used mainly in patients with advanced disease, also led to clinical improvement from the volume reduction, as well as reduced incidence of cellulitis, although with poor cosmetic results; 87.5% of these reports recommended postoperative compression garments. The overall complication rates were 1% for LVA, 13% for VLNT, 11% for SAL, and 46% for extirpative procedures. Altogether, only one paper lacked some kind of improvement. Primary lymphedema is amenable to surgical treatment; the currently performed procedures have effectively improved symptoms and QoL in this population. Complication rates are related to the invasiveness of the chosen procedure.
Collapse
Affiliation(s)
- Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children's Hospital (Hospital Infantil de México “Federico Gómez”), Mexico City, Mexico
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kristin A. Skinner
- Department of Surgical Oncology, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York
| | | |
Collapse
|
2
|
Kuruvilla AS, Shroyer ALW, Li X, Yang J, Mulay SR, Agha SM, Bellis RM, Kohli HK, Tannous HJ, Krajewski A. Risk Factors Associated with Adverse Outcomes after Ablative Surgery for Lymphedema. J Reconstr Microsurg 2023; 39:214-220. [PMID: 36162422 DOI: 10.1055/s-0042-1755258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Postmastectomy breast cancer lymphedema poses an important health threat. Historically, physical therapy was the exclusive treatment option. More recently, lymphedema surgery has revolutionized care. As a first-in-kind, multicenter report, the postmastectomy breast cancer patients' risk factors associated with postlymphedema ablative surgical outcomes were documented. METHODS Using the New York Statewide Planning and Research Cooperative System database from 2010 to 2018, multivariable models identified the postmastectomy breast cancer lymphedema surgical patients' characteristics associated with major adverse outcomes and mortality. RESULTS Of 65,543 postmastectomy breast cancer patients, 1,052 lymphedema surgical procedures were performed including 393 (37.4%) direct excisions and 659 (63.6%) liposuctions. Direct excision and liposuction surgical patients had median ages of 58 and 52 years, respectfully (p < 0.001). Although a 30-day operative mortality was rare (0.3%, all direct excisions), major adverse outcomes occurred in 154 patients (28.5% direct excision; 6.4% liposuction; p < 0.0001). Multivariable clinical outcomes model identified that patients with higher Elixhauser's score, renal disease, emergent admissions, and direct excision surgery had higher incidences of adverse outcomes (all p < 0.01). For those patients with 30-day readmissions (n = 60), they were more likely to have undergone direct excision versus liposuction (12.5 vs. 1.7%; p < 0.0001). The important risk factors predictive of future cellulitis/lymphangitis development included diabetes mellitus, Medicaid insurance, renal disease, prior cellulitis/lymphangitis, chronic obstructive pulmonary disease (COPD), and chronic steroid use (all p < 0.01). CONCLUSION Lymphedema surgery carries a favorable risk profile, but better understanding the "high-risk" patients is critical. As this new era of lymphedema surgery progresses, evaluating the characteristics for adverse postoperative outcomes is an important step in our evolution of knowledge.
Collapse
Affiliation(s)
- Annet S Kuruvilla
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Annie Laurie W Shroyer
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Xiaoning Li
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Jie Yang
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Sagar R Mulay
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Sohaib M Agha
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Raymond M Bellis
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Harmehar K Kohli
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Henry J Tannous
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| | - Aleksandra Krajewski
- Division of Plastic Surgery, Department of Surgery, Stony Brook University, Renaissance School of Medicine, Stony Brook, New York
| |
Collapse
|
3
|
McEvoy MP, Gomberawalla A, Smith M, Boccardo FM, Holmes D, Djohan R, Thiruchelvam P, Klimberg S, Dietz J, Feldman S. The prevention and treatment of breast cancer- related lymphedema: A review. Front Oncol 2022; 12:1062472. [PMID: 36561522 PMCID: PMC9763870 DOI: 10.3389/fonc.2022.1062472] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Background Breast cancer- related lymphedema (BCRL) affects about 3 to 5 million patients worldwide, with about 20,000 per year in the United States. As breast cancer mortality is declining due to improved diagnostics and treatments, the long-term effects of treatment for BCRL need to be addressed. Methods The American Society of Breast Surgeons Lymphatic Surgery Working Group conducted a large review of the literature in order to develop guidelines on BCRL prevention and treatment. This was a comprehensive but not systematic review of the literature. This was inclusive of recent randomized controlled trials, meta-analyses, and reviews evaluating the prevention and treatment of BCRL. There were 25 randomized clinical trials, 13 systemic reviews and meta-analyses, and 87 observational studies included. Results The findings of our review are detailed in the paper, with each guideline being analyzed with the most recent data that the group found evidence of to suggest these recommendations. Conclusions Prevention and treatment of BCRL involve a multidisciplinary team. Early detection, before clinically apparent, is crucial to prevent irreversible lymphedema. Awareness of risk factors and appropriate practice adjustments to reduce the risk aids are crucial to decrease the progression of lymphedema. The treatment can be costly, time- consuming, and not always effective, and therefore, the overall goal should be prevention.
Collapse
Affiliation(s)
- Maureen P. McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States,*Correspondence: Maureen P. McEvoy,
| | - Ameer Gomberawalla
- Department of Surgery, Advocate Medical Group, Oak Lawn, IL, United States
| | - Mark Smith
- Department of Plastic Surgery, Northwell Health System, New Hyde Park, NY, United States
| | | | - Dennis Holmes
- Department of Surgery, Los Angeles Center for Women’s Health, Los Angeles, CA, United States
| | - Risal Djohan
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States
| | - Paul Thiruchelvam
- Department of Breast Surgery, Imperial College, London, United Kingdom
| | - Suzanne Klimberg
- Department of Surgery, University of Texas Medical Branch(UTMB) Cancer Center, Galveston, TX, United States
| | - Jill Dietz
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| |
Collapse
|
4
|
Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69 Suppl 3:e29908. [PMID: 36070213 DOI: 10.1002/pbc.29908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 07/19/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
Collapse
Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
5
|
Pateva I, Greene AK, Snyder KM. How we approach lymphedema in the pediatric population. Pediatr Blood Cancer 2022; 69:e29611. [PMID: 35404535 DOI: 10.1002/pbc.29611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/14/2022] [Accepted: 01/25/2022] [Indexed: 11/10/2022]
Abstract
Lymphedema in children is rare; however, it is usually a progressive and chronic condition. Accurate diagnosis of lymphedema in the pediatric population often takes several months and sometimes is delayed for years. Lymphedema can be isolated or associated with genetic syndromes, thus it is very important to identify the correct diagnosis, to select carefully which patients to refer for genetic testing, and to initiate appropriate treatment in a timely fashion. In this article, we review key information about diagnosis of lymphedema, associated conditions and syndromes, and current treatment modalities.
Collapse
Affiliation(s)
- Irina Pateva
- Pediatric Hematology/Oncology, Rainbow Babies and Children's Hospital, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kristen M Snyder
- Comprehensive Vascular Anomalies Program, Solid Tumor Program, Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
6
|
Sudduth CL, Greene AK. Primary Lymphedema: Update on Genetic Basis and Management. Adv Wound Care (New Rochelle) 2022; 11:374-381. [PMID: 33502936 DOI: 10.1089/wound.2020.1338] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Significance: Primary lymphedema is a chronic condition without a cure. The lower extremities are more commonly affected than the arms or genitalia. The disease can be syndromic. Morbidity includes decreased self-esteem, infections, and reduced function of the area. Recent Advances: Several mutations can cause lymphedema, and new variants continue to be elucidated. A critical determinant that predicts the natural history and morbidity of lymphedema is the patient's body mass index (BMI). Individuals who maintain an active lifestyle with a normal BMI generally have less severe disease compared to subjects who are obese. Because other causes of lower extremity enlargement can be confused with lymphedema, definitive diagnosis requires lymphoscintigraphy. Critical Issues: Most patients with primary lymphedema are satisfactorily managed with compression regimens, exercise, and maintenance of a normal body weight. Suction-assisted lipectomy is our preferred operative intervention for symptomatic patients who have failed conservative therapy. Suction-assisted lipectomy effectively removes excess subcutaneous fibro-adipose tissue and can improve underlying lymphatic function. Future Directions: Many patients with primary lymphedema do not have an identifiable mutation and thus novel variants will be identified. The mechanisms by which mutations cause lymphedema continue to be studied. In the future, drug therapy for the disease may be developed.
Collapse
Affiliation(s)
- Christopher L. Sudduth
- Lymphedema Program, Department of Plastic and Oral Surgery, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Arin K. Greene
- Lymphedema Program, Department of Plastic and Oral Surgery, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Sudduth CL, Maclellan RA, Greene AK. Study of 700 Referrals to a Lymphedema Program. Lymphat Res Biol 2020; 18:534-538. [DOI: 10.1089/lrb.2019.0086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christopher L. Sudduth
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Reid A. Maclellan
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arin K. Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Nassif TM, Brunelle CL, Gillespie TC, Bernstein MC, Bucci LK, Naoum GE, Taghian AG. Breast Cancer-Related Lymphedema: a Review of Risk Factors, Radiation Therapy Contribution, and Management Strategies. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00387-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
9
|
Abstract
Lymphedema is the chronic, progressive swelling of tissue due to inadequate lymphatic function. Over time, protein-rich fluid accumulates in the tissue causing it to enlarge. Lymphedema is a specific disease and should not be used as a generic term for an enlarged extremity. The diagnosis is made by history and physical examination, and confirmed with lymphoscintigraphy. Intervention includes patient education, compression, and rarely, surgery. Patients are advised to exercise, maintain a normal body mass index, and moisturize / protect the diseased limb from incidental trauma. Conservative management consists of compression regimens. Operative interventions either attempt to address the underlying lymphatic anomaly or the excess tissue. Lymphatic-venous anastomosis and lymph node transfer attempt to create new lymphatic connections to improve lymph flow. Suction-assisted lipectomy and cutaneous excision reduce the size of the area by removing fibroadipose hypertrophy.
Collapse
Affiliation(s)
- Arin K Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States.
| | - Christopher L Sudduth
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States
| | - Amir Taghinia
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, United States
| |
Collapse
|
10
|
Ramachandran S, Chew KY, Tan BK, Kuo YR. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J Surg 2020; 44:46-53. [PMID: 32950353 DOI: 10.1016/j.asjsur.2020.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/16/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022] Open
Abstract
Lymphedema is defined as the abnormal accumulation of interstitial fluid in subcutaneous tissues resulting from cancer, cancer treatment (surgery and/or radiotherapy), infection, inflammatory disorders, obesity, and hereditary syndromes. Surgical management of lymphedema can be broadly classified into two categories, reductive surgical techniques such as direct excision, suction assisted protein lipectomy (SAPL) or radical reduction with perforator preservation (RRPP); and physiological surgical procedures such as lymphaticovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT). These techniques and their various combinations were evaluated. The results revealed patients with reversible lymphedema (ISL stage I, mild severity) benefit most from physiological procedures (LVA or VLNT) which can reduce the chance of disease progression to the chronic, solid phase. Reductive techniques such as SAPL, RPPP, or direct excision procedures should be reserved for patients with advanced - severe lymphedema (ISL stages II and especially stage III) as the surgical treatment of choice. In this study, current literature on the surgical treatment of lower extremity lymphedema is reviewed and discussed in conjunction with authors' clinical experiences. An algorithm is presented, based on clinical evidence and experience which aims to provide a structured approach to managing lower limb lymphedema.
Collapse
Affiliation(s)
- Savitha Ramachandran
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Khong-Yik Chew
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Bien-Keem Tan
- Department of Plastic and Reconstructive Surgery, Singapore General Hospital, Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Biological Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan; SingHealth Duke-NUS Musculoskeletal Sciences Academic Clinical Programme, Singapore.
| |
Collapse
|
11
|
Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients. Plast Reconstr Surg 2020; 146:402-407. [PMID: 32740596 DOI: 10.1097/prs.0000000000007021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is a risk factor for the development of secondary lymphedema after axillary lymphadenectomy and radiation therapy. The purpose of this study was to determine whether obesity influences the morbidity of lymphedema in patients who have the condition. METHODS Two cohorts of patients were compared: group 1, normal weight (body mass index ≤25 kg/m); and group 2, obese (body mass index ≥30 kg/m). Inclusion criteria were patients aged 21 years or older with lymphedema confirmed by lymphoscintigraphy. Covariates included age, sex, lymphedema type (primary or secondary), location, comorbidities, lymph node dissection, radiation therapy, lymphoscintigram result, and disease duration. Outcome variables were infection, hospitalization, and degree of limb overgrowth. The cohorts were compared using the Mann-Whitney U test, Fisher's exact test, and multivariable logistic regression. RESULTS Sixty-seven patients were included: group 1, n = 33; and group 2, n = 34. Disease duration did not differ between groups (p = 0.72). Group 2 was more likely to have an infection (59 percent), hospitalization (47 percent), and moderate or severe overgrowth (79 percent), compared to group 1 (18, 6, and 40 percent, respectively; p < 0.001). Multivariable logistic regression showed that obesity was an independent risk factor for infection (OR, 7.9; 95 percent CI, 2.5 to 26.3; p < 0.001), hospitalization (OR, 30.0; 95 percent CI, 3.6 to 150.8; p < 0.001), and moderate to severe limb overgrowth (OR, 6.7; 95 percent CI, 2.1 to 23.0; p = 0.003). CONCLUSIONS Obesity negatively affects patients with established lymphedema. Obese individuals are more likely to have infections, hospitalizations, and larger extremities compared to subjects with a normal body mass index. Patients with lymphedema should be counseled about the negative effects of obesity on their condition. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
Collapse
|
12
|
Discussion: Body Mass Index and Lymphedema Morbidity: Comparison of Obese versus Normal-Weight Patients. Plast Reconstr Surg 2020; 146:408-409. [PMID: 32740597 DOI: 10.1097/prs.0000000000007040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Ziegler UE, Lorenz U, Zeplin PH. Lower Leg Lifts in Patients After Massive Weight Loss in Obesity-Associated Lipoedema. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02163-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Lymphedema Liposuction with Immediate Limb Contouring. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2513. [PMID: 31942304 PMCID: PMC6908351 DOI: 10.1097/gox.0000000000002513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 09/06/2019] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is available in the text. Liposuction is the treatment of choice for solid predominant extremity lymphedema. The classic lymphedema liposuction technique does not remove skin excess created following bulk removal. The skin excess is presumed to resolve with spontaneous skin contracture. We investigated the technique of simultaneously performing liposuction with immediate skin excision in patients with solid predominant lymphedema and compared the outcome with that from the classic technique.
Collapse
|
16
|
Forte AJ, Huayllani MT, Boczar D, Ciudad P, McLaughlin SA. Lipoaspiration for the Treatment of Lower Limb Lymphedema: A Comprehensive Systematic Review. Cureus 2019; 11:e5913. [PMID: 31754590 PMCID: PMC6827692 DOI: 10.7759/cureus.5913] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Lipoaspiration is a potential treatment for lymphedema; however, there is a lack of knowledge regarding the outcomes and benefits of this procedure in lower limb lymphedema. We aim to describe the outcomes of studies to date reporting the use of lipoaspiration in lower limb lymphedema. We searched the PubMed database for studies that evaluated the use of lipoaspiration for lower limb lymphedema. The keywords “lipoaspiration” AND “lymphedema,” synonyms, and different combinations were used for the search. Only English studies were included. Eight studies met the inclusion criteria from a total of 129 articles. A volume reduction greater than 50% was found in all patients who underwent lipoaspiration for lower limb lymphedema. Complete volume reduction was found after four to five years of follow-up. A greater volume reduction was found for secondary lymphedema when compared to primary lymphedema. Finally, improvement was found in functionality, quality of life, and rate of infection. Lipoaspiration is recommended for patients with lower limb lymphedema in stages 2 and 3 of the disease, followed by controlled compressive therapy that maintains the volume reduction accomplished by the procedure.
Collapse
Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Pedro Ciudad
- Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, PER
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| |
Collapse
|
17
|
Optimal Sites for Supermicrosurgical Lymphaticovenular Anastomosis: An Analysis of Lymphatic Vessel Detection Rates on 840 Surgical Fields in Lower Extremity Lymphedema Patients. Plast Reconstr Surg 2019; 142:924e-930e. [PMID: 30239498 DOI: 10.1097/prs.0000000000005042] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Supermicrosurgical lymphaticovenular anastomosis is becoming a useful treatment option for progressive lower extremity lymphedema because of its minimal invasiveness. Finding a lymphatic vessel is a minimum requirement for lymphaticovenular anastomosis surgery, but no study has reported comprehensive analysis on factors associated with lymphatic vessel detection. METHODS One hundred thirty-four female secondary lower extremity lymphedema patients who underwent indocyanine green lymphography and lymphaticovenular anastomosis without a history of lymphedema surgery were included. Medical charts were reviewed to obtain clinical, indocyanine green lymphographic, and intraoperative findings. Lymphatic vessel detection was defined as positive when one or more lymphatic vessels were found in a surgical field of lymphaticovenular anastomosis. Logistic regression analysis was used to identify independent factors associated with lymphatic vessel detection. RESULTS Patient age ranged from 36 to 81 years, duration of edema ranged from 3 to 324 months, and body mass index ranged from 16.2 to 33.3 kg/m. Forty-eight patients (35.8 percent) had a history of radiation therapy, and 76 patients (56.7 percent) had a history of cellulitis. Lymphaticovenular anastomoses were performed in 840 surgical fields, among which lymphatic vessel detection was positive in 807 fields; the overall lymphatic vessel detection rate was 96.1 percent. Multivariate analysis revealed inverse associations in higher body mass index (OR, 0.323; p = 0.008) and the S-region/D-region on indocyanine green lymphography compared with the L-region (OR, 1.049 × 10(-8)/1.724 × 10(-9); p < 0.001/p < 0.001). CONCLUSIONS Independent factors associated with lymphatic vessel detection were clarified. Lower body mass index and L-region on indocyanine green lymphography are favorable conditions for finding lymphatic vessels in lower extremity lymphedema patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
|
18
|
Goss JA, Maclellan RA, Greene AK. Primary Lymphedema of the Upper Extremities: Clinical and Lymphoscintigraphic Features in 23 Patients. Lymphat Res Biol 2019; 17:40-44. [DOI: 10.1089/lrb.2017.0085] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeremy A. Goss
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reid A. Maclellan
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arin K. Greene
- Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
19
|
Tokumoto H, Akita S, Kuriyama M, Mitsukawa N. Utilization of Three-Dimensional Photography (VECTRA) for the Evaluation of Lower Limb Lymphedema in Patients Following Lymphovenous Anastomosis. Lymphat Res Biol 2018; 16:547-552. [DOI: 10.1089/lrb.2017.0058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hideki Tokumoto
- Department of Plastic and Reconstructive Surgery, Chiba Cancer Center Hospital, Chiba, Japan
| | - Shinsuke Akita
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| | - Motone Kuriyama
- Department of Plastic and Reconstructive Surgery, Kochi Medical School Hospital, Kochi, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Chiba University, Chiba, Japan
| |
Collapse
|
20
|
Johnson AR, Singhal D. Immediate lymphatic reconstruction. J Surg Oncol 2018; 118:750-757. [DOI: 10.1002/jso.25177] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 06/28/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Anna Rose Johnson
- Division of Plastic and Reconstructive SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBoston Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBoston Massachusetts
| |
Collapse
|
21
|
Gillespie TC, Sayegh HE, Brunelle CL, Daniell KM, Taghian AG. Breast cancer-related lymphedema: risk factors, precautionary measures, and treatments. Gland Surg 2018; 7:379-403. [PMID: 30175055 DOI: 10.21037/gs.2017.11.04] [Citation(s) in RCA: 170] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Breast cancer-related lymphedema (BCRL) is a negative sequela of breast cancer treatment, and well-established risk factors include axillary lymph node dissection (ALND) and regional lymph node radiation (RLNR). BCRL affects approximately 1 in 5 patients treated for breast cancer, and it has a significant negative impact on patients' quality of life after breast cancer treatment, serving as a reminder of previous illness. This paper is a comprehensive review of the current evidence regarding BCRL risk factors, precautionary guidelines, prospective screening, early intervention, and surgical and non-surgical treatment techniques. Through establishing evidence-based BCRL risk factors, researchers and clinicians are better able to prevent, anticipate, and provide early intervention for BCRL. Clinicians can identify patients at high risk and utilize prospective screening programs, which incorporate objective measurements, patient reported outcome measures (PROM), and clinical examination, thereby creating opportunities for early intervention and, accordingly, improving BCRL prognosis. Innovative surgical techniques that minimize and/or prophylactically correct lymphatic disruption, such as axillary reverse mapping (ARM) and lymphatic-venous anastomoses (LVAs), are promising avenues for reducing BCRL incidence. Nonetheless, for those patients with BCRL who remain unresponsive to conservative methods like complete decongestive therapy (CDT), surgical treatment options aiming to reduce limb volume or restore lymphatic flow may prove to be palliative or corrective. It is only through a strong team-based approach that such a continuum of care can exist, and a multidisciplinary approach to BCRL screening, intervention, and research is therefore strongly encouraged.
Collapse
Affiliation(s)
- Tessa C Gillespie
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Hoda E Sayegh
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Cheryl L Brunelle
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Kayla M Daniell
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
22
|
Abstract
In the Western world, lymphedema most commonly occurs following treatment of cancer. Limb reductions have been reported utilizing various conservative therapies including manual lymph and pressure therapy, as well as by microsurgical reconstruction involving lymphovenous shunts and transplantation of lymph vessels or nodes. Failure of these conservative and surgical treatments to provide complete reduction in patients with long-standing pronounced lymphedema is due to the persistence of excess newly formed subcutaneous adipose tissue in response to slow or absent lymph flow, which is not removed in patients with chronic non-pitting lymphedema. Traditional surgical regimes utilizing bridging procedures, total excision with skin grafting, or reduction plasty seldom achieved acceptable cosmetic and functional results. Liposuction removes the hypertrophied adipose tissue and is a prerequisite to achieve complete reduction, and this reduction is maintained long-term through constant (24 h) use of compression garments postoperatively. This article describes the techniques and evidence basis for the use of liposuction for treatment of lymphedema.
Collapse
Affiliation(s)
- Mark V Schaverien
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - D Alex Munnoch
- Department of Plastic and Reconstructive Surgery, Ninewells Hospital and Medical School, Dundee, United Kingdom
| | - Håkan Brorson
- Department of Clinical Sciences, Lund University, Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
23
|
|
24
|
Yang Y, Yang JT, Chen XH, Qin BG, Li FG, Chen YX, Gu LQ, Zhu JK, Li P. Construction of tissue-engineered lymphatic vessel using human adipose derived stem cells differentiated lymphatic endothelial like cells and decellularized arterial scaffold: A preliminary study. Biotechnol Appl Biochem 2017; 65:428-434. [PMID: 28981171 DOI: 10.1002/bab.1618] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/29/2017] [Indexed: 12/19/2022]
Abstract
We have previously demonstrated that human adipose-derived stem cells (hADSCs) can be differentiated into lymphatic endothelial like cells. The purpose of this study was to investigate the feasibility of utilizing the induced lymphatic endothelial like cells and decellularized arterial scaffold to construct the tissue-engineered lymphatic vessel. The hADSCs were isolated from adipose tissue in healthy adults and were characterized the multilineage differentiation potential. Decellularized arterial scaffold was prepared using the Triton x-100 method. ADSCs were differentiated into lymphatic-like endothelial cells, and the induced cells were then seeded onto the decellularized arterial scaffold to engineer the lymphatic vessel. The histological analyses were performed to examine the endothelialized construct. The decellularized arterial scaffold was successfully obtained and was able to maintain its vessel morphology. The isolated ADSCs can be differentiated into osteocytes and adipocytes. After seeding onto the scaffold, the seeded cells attached and grew well on the decellularized arterial scaffold. Our preliminary results demonstrated that the induced lymphatic endothelial like cells combined with decellularized arterial scaffold could be utilized to successfully engineer the lymphatic vessel. Our findings may be helpful for the development of tissue-engineering of the lymphatic graft.
Collapse
Affiliation(s)
- Yi Yang
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jian-Tao Yang
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xiao-Hu Chen
- Department of Orthopedic Trauma, The Hui Ya Hospital of Sun Yat-sen University, Huizhou, People's Republic of China
| | - Ben-Gang Qin
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Fu-Gui Li
- Department of Cancer Institute, The Zhong Shan Hospital of Sun Yat-sen University, Zhongshan, People's Republic of China
| | - Yun-Xian Chen
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Qiang Gu
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jia-Kai Zhu
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Ping Li
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| |
Collapse
|
25
|
Beijnen UEA, Maclellan RA, Goss JA, Couto JA, Konczyk DJ, Greene AK. Beckwith-Wiedemann Syndrome and Primary Lymphedema of the Lower Extremity. Pediatr Dermatol 2017; 34:e51-e53. [PMID: 27778389 DOI: 10.1111/pde.13017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Beckwith-Wiedemann syndrome is the most common genetic overgrowth syndrome. Patients with Beckwith-Wiedemann syndrome may have hemihypertrophy, but their lymphatic vasculature is intact. We present a child with Beckwith-Wiedemann syndrome and lower extremity enlargement thought to be due to hemihypertrophy that was instead diagnosed with primary lymphedema. There are many causes of leg overgrowth in the pediatric population and misdiagnosis is common. While extremity enlargement secondary to hemihypertrophy may occur in 15% of patients with Beckwith-Wiedemann syndrome, progression and pitting edema only occur in primary lymphedema. This report highlights the importance of ensuring an accurate diagnosis so that patients are managed appropriately.
Collapse
Affiliation(s)
- Usha E A Beijnen
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Reid A Maclellan
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeremy A Goss
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Javier A Couto
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dennis J Konczyk
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Arin K Greene
- Department of Plastic and Oral Surgery, Vascular Anomalies Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|