ArticleLiterature Review

Surgical Treatment of Congenital Lymphedema

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Abstract

Lymphedema is a pathologic condition that results from a disturbance of the lymphatic system, with localized fluid retention and tissue swelling. Primary lymphedema is a congenital disorder, caused by a malformation of lymph vessels or nodes. Major progress has been achieved in the radiologic diagnosis of patients affected by lymphedema. The ideal treatment of the affected limb should restore function and cosmetic appearance. Surgical treatment is an alternative method of controlling chronic lymphedema. Free lymph nodes autologous transplantation is a new approach for lymphatic reconstruction in hypoplastic forms of primary lymphedema. The transferred nodes pump extracellular liquid out of the affected limb and contain germinative cells that improve immune function.

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... 2 Inguinal lymph node dissection and radiotherapy to the groin exposes patients under oncological treatment of the legs or pelvic structures to similar risks of developing lymphedema as the breast cancer population. 3 Large efforts have been made by the microsurgical community to generate better evidence to support reconstructive approaches to the lymphatic system. Many techniques have been proposed and have shown variable results. ...
... LNFT has been proposed by the senior author 12 and performed extensively over the last 15-20 years. 3,[12][13][14][15][16] However, there is still very little evi-dence of its benefits for patients with lower limb lymphedema. ...
... The flap can be harvested from the patient at multiple locations, but preferably at the lateral thoracic area. 3 It is thought that the transferred flap may improve the clearance of lymph by stimulating lymphatic growth and reconnection of the limb lymphatic system; however, it would be unreasonable to think that it could regenerate distal lymphatic ducts. Patients with more severe presentations might be good candidates for a second lymphatic flap at a more distant site if the excess fluid persists distally. ...
Article
Previous authors have shown benefits from the use of lymph node flap transfer (LNFT) to treat lymphedema of the arms, but there is little evidence for its use for lower limb lymphedema. We performed a retrospective analysis of a series of patients suffering from secondary lower limb lymphedema treated with a free LNFT. 52 cases of LNFT to treat 41 legs in 38 patients with secondary lymphedema were retrospectively reviewed. The causes of the lymphedema included lymphedema secondary to hysterectomy for uterine cancer, melanoma resections on the leg, lymphoma treatment and testicular cancer, cosmetic surgery to the limb, lipoma resection at the inguinal region, and a saphenectomy. Patients had been suffering with lymphedema for an average of 9.1 ± 7.3 years at the time of LNFT. Eleven patients (28.9%) presented with minor complications treated conservatively. For 23 legs there was enough data to follow limb volume evolution after a single LNFT. Total volume reduction in eight legs (two patients with no measures of the healthy limb and three bilateral) was 7.1 ± 8.6%. Another group of 15 patients with unilateral lymphedema had an average 46.3 ± 34.7% reduction of excess volume. Better results (>30% REV) were associated with smaller preoperative excess volume (P = 0.045). Patients with secondary leg lymphedema can benefit from LNFT. Results in patients with mild presentations seem to be better than in more severe cases. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015. © 2015 Wiley Periodicals, Inc.
... Lymphedema is a chronic condition caused by the obstruction or impairment of lymphatic fluid transport, leading to edema, inflammation and cellulitis, and in time, to irreversible changes such as fibrosis and an excess of adipose tissue (Brorson et al., 2006). Primary lymphedema is characterized by a disturbance in normal lymphatic flow through hyperplasia, hypoplasia, aplasia of lymphatic vessels or valvular dysfunction (Becker et al., 2012;Liu et al., 2014;Rustgi et al., 1985). Secondary lymphedema is caused by mechanical obstruction of lymphatic vessels due to lymphadenectomies for oncologic surgery of the extremities or breast, frequently leaving patients with chronic and debilitating lymphedema and only a limited number of treatment options. ...
... This study revealed an improved postoperative extremity circumference in patients over 11 years of age, while lymphedema worsened in patients 11 years or younger. Several studies have shown a genetic basis for some forms of primary lymphedema, including a possible relation with the VEGFR3 signaling pathway (Hara et al., 2015), which may lead to hyperplasia, hypoplasia, aplasia, or valvular dysfunction of lymphatic vessels (Akita et al., 2014;Becker et al., 2012;Mendola et al., 2013;Rustgi et al., 1985) Primary lymphedema is commonly categorized into congenital, praecox (<35 years), or tarda (>36 years) lymphedema (Kinmonth & Eustace, 1976), although a biological basis for this classification is still lacking, as was also underlined by Hara and colleagues (Akita et al., 2014). Importantly, we found no biological evidence necessitating a further differentiation of primary lymphedema patients into <11 years and >11 years of age, as was performed in the study by Hara and colleagues. ...
Article
Introduction: Lymphedema is a chronic condition caused by the obstruction or impairment of lymphatic fluid transport resulting in irreversible skin fibrosis. Besides conservative therapy, surgical techniques for lymphedema including liposuction, lymphatico-lymphatic bypass, lymphovenous anastomosis (LVA), and vascularized lymph node transfer (VLNT) are options with increasing popularity in the recent past. In our review, we investigated the efficacy of LVA for the treatment of lymphedema. Both objective and subjective outcomes of surgical treatment were evaluated. Methods: Studies were identified through systematic review in PubMed database up to September 2016. Only original Articles which exclusively performed LVA for lymphedema treatment were included. Our primary endpoint was the objective of a subjective postoperative lymphedema reduction. Results: A total of 293 titles were identified, out of which 18 studies including 939 patients were deemed eligible. The studies included in this review describe significant variations in surgical techniques, number of anastomoses and supplementary interventions. All studies reported objective reductions in circumference measurements. Subjective symptom relief was found in 50-100% of the patients as well as a reduction in the number of cellulitis episodes in all investigated cases. Conclusion: Although the studies included in this review showed great heterogeneity, LVA surgery revealed both objective and subjective improvements in most patients.
... Although the efficacy of surgical procedures for primary lymphedema has been reported, the evidence is insufficient to determine which procedure is optimal. 1,2,9,10 We usually perform lymphaticovenous anastomosis for patients with either primary or secondary lymphedema. [11][12][13][14] Lymphaticovenous anastomosis can be performed under local anesthesia, except in pediatric cases, and is minimally invasive, requiring only a small skin incision (only a few centimeters). ...
... This may be related to the presence of lymphatic hypoplasia in these patients, suggesting that vascularized lymph node transfer may be indicated in these cases. 2 As revealed by indocyanine green lymphography, lymphedema started from the proximal lower limb in 40.5 percent of cases in the present study. Although primary lymphedema of the lower limb is generally believed to start proximally and secondary lymphedema is believed to start distally, we demonstrated that many of the primary lymphedema patients had lymphedema starting on the proximal side. ...
Article
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Lymphedema can be classified as either primary or secondary, depending on its etiology. In the present study, we aimed to investigate the efficacy of lymphatico-venous anastomosis (LVA) for correcting primary lower limb lymphedema and to determine its indications and contraindications. We retrospectively examined patients with primary lower limb lymphedema who underwent LVA between April 2009 and September 2013. LVA efficacy was evaluated using lower limb circumference measurements at five anatomic locations. Lymphedema staging was determined according to the patient's modified leg dermal backflow (LDB) stage. We added two categories to the standard LDB staging system: no backflow and distal backflow. LVA was performed under local anesthesia, except in pediatric cases. We evaluated 62 patients (79 lower limbs, 70 LVA procedures). Lower limb circumference increased after LVA therapy in patients with an onset age of ≥1 years and <11 years, but it significantly decreased in patients with an onset age of >11 years. The presence of lymphedema for a longer period did not negatively impact LVA efficacy. In particular, LVA was effective in the LDB stage 2 and no backflow group. LVA was effective for treating primary lower limb lymphedema. For patients developing lymphedema prior to 11 years of age, the indications should be carefully considered. However, LVA was effective in patients developing lymphedema after the age of 11 years. Regardless, due to its low level of invasiveness, LVA may be considered for patients who are refractory to conservative treatment, even if they have early-onset lymphedema. Therapeutic study level III.
... • Autologous lymph-node transplants may come from cervical, axillary or inguinal donor sites. Few publications of rigorous methodological quality are available, with a notable lack of objective volumetric evaluation [66]. In addition, a definite risk of inducing complications exists, particularly lymphedema at the donor site, but also lymphocele, hydrocele or local hypoesthesia [67]. ...
Article
Full-text available
Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 ( https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf ). Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major, deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.
... 27e30 If lymphatic aplasia is suspected, as in the NE pattern, lymphatic bypass would be impossible and vascularized lymph node transfer and/or debulking surgery would be more appropriate. 26,31,32 Outcome studies are required to confirm the usefulness of the classification for lymphedema management. ...
Article
Indocyanine green (ICG) lymphography has been reported to be useful for the evaluation of secondary lymphedema, but no study has reported characteristic findings of ICG lymphography in primary lymphedema. This study aimed to classify characteristic ICG lymphography patterns in primary lymphedema. The study was a retrospective observational study. Thirty one primary lower extremity lymphedema (LEL) patients with a total of 62 legs were studied. ICG lymphography patterns were categorized according to the visibility of lymphatics and dermal backflow (DB) extension. Clinical demographics were compared with categorized ICG lymphography patterns. All symptomatic legs showed abnormal patterns, and all asymptomatic legs showed normal patterns on ICG lymphography. Abnormal lymphographic patterns could be classified into proximal DB (PDB), distal DB (DDB), less enhancement (LE), and no enhancement (NE) patterns. There were significant differences between PDB (16 patients), DDB (6 patients), LE (4 patients), and NE patterns (5 patients) in age (37.3 ± 18.3 vs. 61.8 ± 19.2 vs. 50.8 ± 27.7 vs. 29.2 ± 18.0 years, p = .035), onset of edema (23.9 ± 19.4 vs. 46.8 ± 27.0 vs. 43.0 ± 31.3 vs. 6.6 ± 14.2 years, p = .020), laterality (bilateral; 18.8% vs. 66.7% vs. 75.0% vs. 0%, p = .016), cellulitis history (56.3% vs. 100% vs. 25.0% vs. 0%, p = .007), and LEL index (292.2 ± 32.8 vs. 254.2 ± 28.6 vs. 243.3 ± 9.4 vs. 295.2 ± 44.8, p = .016). ICG lymphography findings in primary lymphedema could be classified into four patterns with different patient characteristics. Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
... It originates from causal mutations affecting lymphatic development and usually involves the lower extremities of female patients. Milroy syndrome (Vascular endothelial growth factor receptor-3 [VEGFR-3] encoding gene), Meige syndrome (mutation unknown), lymphedemadistichiasis (FOXC2 on chromosome 16), and yellow nail syndrome are hereditary diseases associated with primary lymphedema [4,5]. ...
Article
Chronic secondary lymphedema is a well-known complication in oncologic surgery. Autologous lymph node transplantation, lymphovenous anastomosis, and other lymphatic surgeries have been developed in the last decades with rising clinical application. Animal models to explore the pathophysiology of lymphedema and microsurgical interventions have reached great popularity, although the induction of stable lymphedema in animals is still challenging. The aim of this review was to systematically assess lymphedema animal models and their potential use to study surgical interventions. A systematic review according to the PRISMA guidelines was performed without time or language restriction. Studies describing new or partially new models were included in chronological order. Models for primary and secondary lymphedema were assessed, and their potential for surgical procedures was evaluated. The systematic search yielded 8590 discrete articles. Of 180 articles included on basis of title, 84 were excluded after abstract review. Ninety-six were included in the final analysis with 24 key articles. No animal model is perfect, and many models show spontaneous lymphedema resolution. The rodent limb appears to be the most eligible animal model for experimental reconstruction of the lymphatic function as it is well accessible for vascularized tissue transfer. There is a need for standardized parameters in experimental lymphedema quantification. Also, more permanent models to study the effect of free vascularized lymph node transfer are needed. Copyright © 2015 Elsevier Inc. All rights reserved.
... Lymphedema is a chronic disease with a progressively ingravescent evolvement and an appearance of recurrent complications of acute lymphangitic type;in nature it is mostly erysipeloid and responsible for a further rapid increase in the volume and consistency of edema [1]. ...
Article
Full-text available
Lymphedema is a chronic disease with a progressively ingravescent evolvement and an appearance of recurrent complications of acute lymphangitic type; in nature it is mostly erysipeloid and responsible for a further rapid increase in the volume and consistency of edema. The purpose of this work is to present our experience in the minimally invasive treatment for recurrence of lymphedema; adapting techniques performed in the past which included large fasciotomy with devastating results cosmetically; but these techniques have been proposed again by the use of endoscopic equipment borrowed from the advanced laparoscopy surgery, which allows a monoskin access of about one cm.
... Orthotopically placed lymph nodes may act as a sponge to absorb lymphatic fluid and direct it into the vascular network, and/or the transferred nodes may induce lymphangiogenesis. [25][26][27] Although some researchers have experimented in animal models with grafting avascular whole nodes or lymph node fragments, their viability is highly variable. 28,29 In general, it has been shown that preserving the vascular supply during transfer results in greater improvements of the edema and better lymphatic function. ...
Article
Background: Secondary lymphedema is a dreaded complication that sometimes occurs after treatment of malignancies. Management of lymphedema has historically focused on conservative measures, including physical therapy and compression garments. More recently, surgery has been used for the treatment of secondary lymphedema. Methods: This article represents the experience and treatment approaches of 5 surgeons experienced in lymphatic surgery and includes a literature review in support of the techniques and algorithms presented. Results: This review provides the reader with current thoughts and practices by experienced clinicians who routinely treat lymphedema patients. Conclusion: The medical and surgical treatments of lymphedema are safe and effective techniques to improve symptoms and improve quality of life in properly selected patients.
... Surgery for lymphedema is one of the new frontiers in reconstructive plastic surgery. [1][2][3][4][5] Limb volume changes have been used as an outcome measure to evaluate the efficacy of surgical treatment for lymphedema. 6 Different measuring methods have been used to determine changes in the relative excess volume of the affected limb relative to the contralateral healthy one. ...
Article
Background Limb circumference measurements (CM) and perometry are the preferred methods for objectively measuring arm volume in lymphedema surgery research. Understanding the measurement bias involved in these measuring systems is important to properly interpret and compare studies and their results. Methods Arm volumes from 91 patients were measured using sequential girths and the truncated cone formula (CM) and with the use of an automated perometer (perometry). The absolute volume of the largest arm (V), the volume difference between the arms (VD), and the relative difference between them (percentage of excess volume [PEV]) were calculated with both methods. The agreement between methods was assessed by the Pearson's correlation test and the Bland–Altman's method. Results Correlations were strong for V (r = 0.99), VD (r = 88), and PEV (r = 0.86). Volumes measured by perometry were, on average, 10.6 mL smaller than volumes calculated from CM, while their limits of agreement (LOA) ranged from −202 to 181 mL. The LOA represents the range we could expect the arm volumes measured with the two methods to differ by chance alone, 95% of the times. For VD, LOA was −101 to 141 mL, with a mean difference of 19.9 mL, while PEV had a mean difference of 0.9%, with LOA ranging from −5 to 6.8%. Conclusion There is considerable measurement error between arm volume estimated by perometry and by CM. Volumes calculated with these methods should be compared with caution. Furthermore, we observed an increasingly relevant measurement bias in outcomes that are mathematically derived from arm volumes.
... Surgery for lymphedema is one of the new frontiers in reconstructive plastic surgery. [1][2][3][4][5] Limb volume changes have been used as an outcome measure to evaluate the efficacy of surgical treatment for lymphedema. 6 Different measuring methods have been used to determine changes in the relative excess volume of the affected limb relative to the contralateral healthy one. ...
Article
BACKGROUND: Limb circumference measurements (CM) and perometry are the preferred methods for objectively measuring arm volume in lymphedema surgery research. Understanding the measurement bias involved in these measuring systems is important to properly interpret and compare studies and their results. METHODS: Arm volumes from 91 patients were measured using sequential girths and the truncated cone formula (CM) and with the use of an automated perometer (perometry). The absolute volume of the largest arm (V), the volume difference between the arms (VD), and the relative difference between them (percentage of excess volume [PEV]) were calculated with both methods. The agreement between methods was assessed by the Pearson's correlation test and the Bland-Altman's method. RESULTS: Correlations were strong for V (r = 0.99), VD (r = 88), and PEV (r = 0.86). Volumes measured by perometry were, on average, 10.6 mL smaller than volumes calculated from CM, while their limits of agreement (LOA) ranged from -202 to 181 mL. The LOA represents the range we could expect the arm volumes measured with the two methods to differ by chance alone, 95% of the times. For VD, LOA was -101 to 141 mL, with a mean difference of 19.9 mL, while PEV had a mean difference of 0.9%, with LOA ranging from -5 to 6.8%. CONCLUSION: There is considerable measurement error between arm volume estimated by perometry and by CM. Volumes calculated with these methods should be compared with caution. Furthermore, we observed an increasingly relevant measurement bias in outcomes that are mathematically derived from arm volumes.
... Another VLNT indication reported was hypoplastic congenital lymphedema. [66] Altogether, despite controversy related to the results' reproducibility, reconstructive microsurgery can provide good effects with reports of up to 87% subjective and 83% objective improvement in the centers of excellence. [55] Timing of the intervention is a crucial factor as well as patient compliance with the life-long medical therapy. ...
Article
Full-text available
The lymphatic system is essential for normal body function, as its role is to recover fluid passed to the interstitial tissue from capillaries and to carry it back to the systemic circulation. This review presents briefly the magnitude of the problem first and then focuses on recent key advances and controversies in contemporary management. Lymphedema touches millions of individuals and generates considerable financial burden for the healthcare system. This frequently debilitating disease requires lifelong treatments in most of the cases. Lymphedema can be significantly improved with comprehensive management including always decongestive physiotherapy, compression pumps, and garments. Drug therapy and surgical treatment are optional. Surgical interventions can be reconstructive or excisional. Therapeutic strategies often combine several methods and should be adapted to each patient. At all times, the patient's values and quality of life should be considered. Although nonperfect and in majority of cases noncurative, the therapeutic options are available and they are efficient. Future research efforts should bring better solutions and will improve patients' evaluation and management.
... Conservative treatment methods include roasting therapy, intermittent compression therapy and so on. If the edema and fibrosis is aggravated, surgical treatment might be required (Becker et al., 2012). And the key to treat MD is figuring out how the lymphedema come into being, and we still need more evidences. ...
Article
Full-text available
Background: Milroy disease (MD) is rare and autosomal dominant resulting from mutations of the vascular endothelial growth factor receptor-3 (VEGFR-3 or FLT4), which leads to dysgenesis of the lymphatic system. Methods: Here we report a Chinese MD family with 2 affected members of two generations. We identified the mutation of c.3075G>A in one allele of FLT4 in Chinese population firstly. The father and child presented lymphedema under knees both. Unfortunately, the child was premature delivered for a car accident of the mother and then died of asphyxia. Then we gathered the tissue of the lower-limb from the child with permission from the parents and ethic committee. We stained the tissue with lymphatic marker D2-40 and hematoxylin-eosin to explore the histological changes. Afterwards, we compared the results with a normal child who unfortunately died of premature delivery also. Results: It is firstly identified the mutation of FLT4: c.3075G>A in Chinese population, and the mutation Inherited in the lineage. The histological evaluation indicated: (1) The number of lymphatic vessels decreased; (2) The morphology and structure of lymphatic vessels was abnormal. And what is added to our knowledge: (1) Capillary hyperemia and phlebectasia is severe; (2) Vascular malformations; (3) The number of vascular endothelial cells and vascular smooth muscle cells decreased; (4) Large sheets of epidermis desquamated; (5) The numbers of cutaneous appendages reduced in MD. Conclusions: Based on the new findings, we assume that mutation of FLT4 not only affect the lymphogenesis, but also the angiogenesis, and epidermis structure.
... 3 Primary lymphedema is characterized by a disruption in normal lymphatic fluid transport due to agenesis or dysgenesis of any component of the lymphatic network. [4][5][6][7][8] Occasionally, a lymphatic thrombus may be the cause. 9 Secondary lymphedema is caused by mechanical obstruction of lymphatic drainage due to trauma, infection, radiation, or surgical disruption. ...
Article
Full-text available
Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included “lymphovenous” OR “lymphaticovenous” AND “bypass” OR “anastomosis” OR “shunt” AND “lower extremity lymphedema.” Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.
... The technical procedure has been described previously. 6,7 Briefly, the axillary or inguinal donor-site area was meticulously dissected. Lymph nodes were harvested with an abundant amount of surrounding fat and were then transplanted into the axillary or inguinal receiving site of the lymphoedematous limb. ...
Article
OBJECTIVE: This study aims to assess potential complications of autologous lymph-node transplantation (ALNT) to treat limb lymphoedema. DESIGN: Prospective, observational study. METHOD: All limb-lymphoedema patients, followed up in a single lymphology department, who decided to undergo ALNT (January 2004-June 2012) independently of our medical team, were included. RESULTS: Among the 26 patients (22 females, four males) included, 14 had secondary upper-limb lymphoedema after breast-cancer treatment and seven had secondary and five primary lower-limb lymphoedema. Median (interquartile range, IQR) ages at primary lower-limb lymphoedema and secondary lymphoedema onset were 18.5 (13-30) and 47.4 (35-58) years, respectively. Median body mass index (BMI) was 25.9 (22.9-29.3) kg m(-2). For all patients, median pre-surgery lymphoedema duration was 37 (24-90) months. Thirty-four ALNs were transplanted into the 26 patients, combined with liposuction in four lower-limb-lymphoedema patients. Ten (38%) patients developed 15 complications: six, chronic lymphoedema (four upper limb, two lower limb), defined as ≥2-cm difference versus the contralateral side, in the limb on the donor lymph-node-site territory, persisting for a median of 40 months post-ALNT; four, post-surgical lymphocoeles; one testicular hydrocoele requiring surgery; and four with persistent donor-site pain. Median (IQR) pre- and post-surgical lymphoedema volumes, calculated using the formula for a truncated cone, were, respectively, 1023 (633-1375) ml (median: 3 (1-6) months) and 1058 (666-1506) ml (median: 40 (14-72) months; P = 0.73). CONCLUSION: ALNT may engender severe, chronic complications, particularly persistent iatrogenic lymphoedema. Further investigations are required to evaluate and clearly determine its indications.
... LNT and autologous lymph node transplantation are reconstructive techniques that have been developed mainly as prevention or treatment of secondary lymphoedema after breast cancer treatment. The available case reports testify complete normalization in 20% of patients 204 (Fig. 6e-f; Supplementary Fig. 1h-i). LNT has been associated with lymphoedema occurring on asymptomatic limbs in patients with PLE 205 . ...
Article
Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment. Primary lymphoedema (PLE) refers to swelling of parts of the body (usually limbs) caused by anomalies in the development or functioning of the lymphatic system; PLE can result from genetic mutations and can be the only symptom or one of the manifestations of a syndrome.
... VLNT comprises the transplant of vascularized autologous lymph nodes from a donor site and anastomosis to recipient vessels in the affected limb. It has been theorized that the transferred lymph nodes act as a sponge that absorbs the excess of lymph fluid while generating a local lymphatic system de novo by lymphangiogenesis [15][16][17]. Despite that these proposals have not been proven, studies have shown an average volume reduction from 7.13 to 74.5% and a reduction for the necessity for long-term compression therapy [18,19], although it has been argued that there is a lack of reproducibility of studies obtaining these outcomes [20]. ...
Article
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Background Lymphedema is a condition that affects up to 130 million subjects worldwide. Since it is related to several complications and a significant reduction in terms of quality of life, it is a heavy burden not only to the patients but also for the healthcare system worldwide. Despite the development of supermicrosurgery, such as vascularized lymph node transfer (VLNT) and lymphovenous anastomosis LVA, the indications and outcomes of these complex groups of interventions remain a controversial topic in the field of reconstructive plastic surgery. Methods This systematic review and network meta-analysis aims to assess the evidence of outcomes of LVA and VLNT in patients with lymphedema. Secondary aims of the project are to determine if for any outcomes, LVA or VLNT is superior to conservative therapy alone, and whether the available evidence favors any kind of supermicrosurgical interventions for lymphedema patients. This study will include original studies of patients with lymphedema on the extremities indexed in PubMed, EMBASE, CENTRAL, PASCAL, FRANCIS, ISTEX, LILACS, CNKI, and IndMED that reported microsurgery (supermicrosurgery) of all techniques aiming the re-functionalization of the lymphatic system. As comparators, mere observation, conservative treatment of any kind, and the other subgroups of supermicrosurgery are planned. The primary outcome of this systematic review and network meta-analysis is the difference of the limb volume, while the secondary outcomes of interest will be erysipelas rates, major and minor complications, postoperative necessity of continuous compression garments, and patient satisfaction, measured by already published and validated scores for quality of life. Discussion We will provide an overview and evidence grade analysis of the scientific literature available on the effectiveness of the subcategories of supermicrosurgical interventions for lymphedema.
Chapter
Lymphoedema is a chronic debilitating disease resulting from an abnormal collection of protein-rich fluid within the subcutaneous tissues. It may be due to aberrant development or malfunction of lymphatic channels or from permanent damage to a normal lymphatic system. Whatever the cause, it is due to an imbalance between capillary filtration and lymph drainage. Initial presentation is with limb swelling, heaviness and pitting. As the disease progresses, fibrosis and fat deposition occur. Developments in near-infrared spectroscopy, lymphoscintigraphy and MR lymphangiography have reinvigorated the role of imaging. Conservative measures are the mainstay of treatment designed to manage the condition rather than to provide a cure. Physiological and reconstructive surgical procedures may improve the lymphatic function of the limb, whereas excisional techniques debulk the limb. Surgical results have been variable and difficult to assess in terms of efficacy. There is a clear need for an unbiased scientific assessment of these techniques with further research.
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Many dermatologic conditions may be present on a newborn infant's upper extremity that can evoke concern for parents and/or primary caregivers. Although the pediatrician typically remains the first care provider, often these children are referred to specialists to diagnose and treat these lesions. Hand surgeons should be familiar with different infantile skin lesions on an upper extremity. Some lesions are best observed, whereas others require treatment with nonoperative measures, lasers, or surgical interventions. A 2-part series is presented to aid the hand surgeon in becoming familiar with these lesions. This part 1 article focuses on vascular neoplasms and malformations. Particular attention is paid to the multiple types of hemangiomas and hemangioendotheliomas, telangiectasias, angiokeratomas, as well as capillary, venous, and lymphatic malformations. Diagnostic tips and clinical photographs are provided to help differentiate among these lesions. In addition, the recommended treatment for each is discussed.
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Primary lower-limb lymphoedema is a chronic, progressive and debilitating condition with a difficult management, especially in advanced cases (elephantiasis). Recently, autologous lymph node transplantation (ALNT) appears to be a promising treatment for extremity lymphoedema. A case of a double ALNT for an advanced primary lower-limb lymphoedema is here reported: a contralateral inguinal lymph node flap was transferred to the knee and, in a second surgery, a thoracic lymph node flap was transplanted to the inguinal region. Clinical outcomes at 5 months postoperatively are very satisfactory with reduction in limb circumferences and improvement in skin quality and social impairment.
Article
Chronic venous disease is manifested by a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. Treatment options range from conservative (eg, medications, compression stockings, lifestyle changes) to minimally invasive (eg, sclerotherapy or endoluminal ablation), invasive (surgical techniques). Deep venous thrombosis of the lower limbs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep venous thrombosis and pulmonary embolism) include the post-thrombotic syndrome. Diagnosis and treatment can reduce the risk of death, and appropriate primary prophylaxis is usually effective. Chronic limb swelling due to lymphedema is not only a marked cosmetic deformity but, in most patients, it is also a disabling condition. Complications can be severe and include bacterial and fungal infections, chronic inflammation, wasting, immunodeficiency, and, occasionally, malignancy.
Article
Objective Lymphedema has a high incidence and various causes. It reduces patients' quality of life and productivity and currently lacks a cure. Management is based on lifelong physical therapies. Many surgical procedures have been proposed for lymphedema without significant acceptance. This study evaluates surgical procedures aimed at the management of lymphedema and highlights present evidence. Methods Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Grading of Recommendations Assessment, Development and Evaluation consensus, a systematic literature search (MEDLINE and The Cochrane Library) was performed to identify studies evaluating treatment outcomes after lymphedema surgery. The authors evaluated all articles found with the keywords “lymphedema” and “surgery,” including experimental studies in animals. Cross referencing was made. Next, a protocol was created to assess the degree of quality of publications in this field. An overview of the complete medical literature was performed. Thereafter, publications meeting inclusion criteria were attributed a score according to the assessment protocol. This allowed an overview of the scientific quality of all surgical procedures for lymphedema. Results A total of 108 article texts were read and 70 publications included in this study according to predefined criteria. Lymphedema operative procedures were classified according to type. The outcomes highlighted the importance of individual patient analysis, as most interventions are not sufficiently studied to sustain clinical recommendations. Conclusions Risk factors for acquired lymphedema, such as lymph node excision and radiation therapy, are well identified and should allow primary prevention. Improved diagnosis, classification, standardized volume measurement, staging, and follow-up of lymphedema patients can facilitate their management and allow valid retrospective studies. Currently, there is no evidence of any treatment yielding high long-term cure rates. Therefore, lymphedema management must be based on interdisciplinary approaches, with curative or palliative therapy options discussed openly with the patient. Therapeutic plans should not exclude surgery. Nevertheless, additional studies are recommended to prove the validity of some surgical approaches.
Article
Background The groin lymph node flap transfer has been used for treatment of extremity lymphedema. The design of this flap is based on the superficial circumflex iliac artery/vein (SCIA/V), or superficial inferior epigastric artery/vein (SIEA/V). The purpose of this study is to delineate the distribution of lymph nodes in the groin area and their relationship to inguinal vessels by the use of multidirector-row CT angiography (MDCTA).MethodsMDCTA was performed in 52 patients who underwent the deep inferior epigastric perforator (DIEP) flap or transverse rectus abdominis musculocutaneous (TRAM) flap for breast reconstruction. The MDCTA data were used to analyze the locations of lymph nodes and their adjacent vascular vessels. The groin region was divided into the superior lateral (I), superior medial (II), inferior lateral (III), and inferior medial (IV) quadrants based on the point where SCIV joined into great saphenous vein. The number of lymph nodes in each of the four quadrants was counted and the dominant vessels were observed.ResultsThe mean number of lymph nodes in quadrants I–IV were 3.3 ± 1.6, 2.0 ± 1.2, 1.5 ± 1.3, and 1.9 ± 1.4, respectively. The difference between the four quadrants was statistically significant (P < 0.001). In quadrant I, the appearance rate of SCIA was 100% while SIEA was 6.6%. In quadrant II, no SCIA was observed but the appearance rate of SIEA was 78.0%. There were neither SCIA nor SIEA observed in quadrants III and IV.Conclusions The superior lateral quadrant of the groin region was found to have the most lymph nodes. The superficial circumflex iliac vessels are the major sources for blood supply to this region. The findings from this study provide evidence for the clinical design of the lymph node flap from the groin area. © 2014 Wiley Periodicals, Inc. Microsurgery, 2014.
Article
Elephantiasis nostras verrucosa (ENV) is a rare cutaneous sequela of chronic lymphedema. Treatment of ENV remains poorly elucidated but has historically involved conservative management aimed at relieving the underlying lymphedema, with a few cases managed by surgical intervention. We report a case of a 27-year-old male with primary lymphedema complicated by large painful ENV lesions on his left foot that we excised surgically with good functional and cosmetic results as validated by the patient. To our knowledge, this is the first report of a case of ENV with a pedunculated morphology and the presence of a deep invasive stalk.
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VFET for the reconstruction of epiphyseal and joint defects in children has shown encouraging results in studies so far, despite insufficient data. Epiphyseal transfers based on the anterior tibial artery and anastomosed in a reverse-flow method were shown to have better results and a lower complication profile at the recipient site. However, VFET's overall complication rate remains high, and harvesting the proximal fibula may result in permanent peroneal nerve paralysis, as per limited available data. A larger sample size, uniformity in evaluation and data and a longer follow�up for each approach may throw more light on the issue and guide reconstructive surgeons to a standardized evidence based protocol.
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Although the coupler does appear to have some advantages over conventional hand-sewn sutures, both techniques work equally well in the hands of an experienced surgeon, and the cost versus benefit ratio must be determined for each individual patient. It is imperative that young trainees continue to learn and practice traditional methods of anastomosis
Article
Background: Surgical management of lymphedema includes removal of affected tissues (excisional procedures), or operations that create new lymphatic connections (physiologic procedures). The purpose of this study was to determine the efficacy of one type of excisional procedure, suction-assisted lipectomy, for extremity lymphedema. Methods: Patients treated in our Lymphedema Program between 2007 and 2015 with liposuction that had postoperative follow-up were reviewed. The diagnosis of lymphedema was made by history/physical examination and confirmed with lymphoscintigraphy. Patient sex, age, type of lymphedema (primary or secondary), location of disease, infection history, volume of lipoaspirate, and reduction of extremity volume were recorded. Results: Fifteen patients were included, mean age was 45 years (range, 17-71). Six patients had secondary upper extremity lymphedema, and 9 patients had lower limb disease. Eight patients had a history of repeated cellulitis involving the lymphedematous extremity. Mean lipoaspirate volume was 1612 mL (range, 1200-2800) for the upper extremity and 2902 mL (range, 2000-4800) for the lower limb. Postoperative follow-up averaged 3.1 years. The mean reduction in excess extremity volume was 73% (range, 48% to 94%), and patients reported improvement in their quality of life. Conclusions: Suction-assisted lipectomy is an effective technique to reduce extremity volume for patients with lymphedema.
Article
Vascularized lymph node transfer to proximal extremity aims to restore physiological lymphatic flow. The main indication for VLNT is secondary lymphedema. It also seems to be beneficial in treatment of chronic pain, neuromas, and brachial plexus neuropathies associated with breast cancer surgery. Wide scar release is an essential step when preparing the recipient site. The most common donor site for a lymph node flap is the inguinal area. It is important to minimize the potential risk of donor-area swelling. Other potential complications include seroma formation and persistent donor-site pain. VLNT is still considered as experimental surgery, and the patient should be informed that complete cure cannot be promised.
Article
Primary lymphedema is idiopathic and affects approximately 1/100,000 people. Males most commonly present in infancy, and females usually develop the condition in adolescence. Primary lymphedema also may occur in adulthood. One or both lower extremities are typically affected. Although the disease usually is sporadic, it can be syndromic and inherited. The involved limb enlarges over time because of subcutaneous adipose deposition. Morbidity includes decreased self-esteem, recurrent infections, difficulty fitting clothing, and reduced function of the area. Definitive diagnosis is achieved using lymphoscintigraphy, which also can determine the severity of lymphatic dysfunction. Management includes protecting the limb from incidental trauma, exercise, and compression. Rarely, operative intervention is indicated to reduce morbidity.
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The mainstay of therapy for early breast cancer is breast conservation treatment (BCT) with whole breast irradiation. Aims of any modality of surgical treatment for breast cancer are a tumor-free resection margin as well as effective local control. Better cosmetic results in breast�conservation treatment were spurred on by improved survival and higher patient expectations. This has prompted surgeons to develop procedures that are both oncologically sound and cosmetically pleasing. The aims of BCT are ablative as well as reconstructive. They include tumour excision without jeopardizing oncological safety, resection bed irradiation, and preservation and/or reconstruction of the breast mound for the optimum aesthetic outcome.
Conference Paper
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Primary lymphedema scrotum and penis may develop at different ages and has approximately the same frequency distribution for men. According to the literature, the number of observations in these patients by different authors, usually small, ranging from isolated cases to 10-30. Recurrent erysipelas may cause a marked increase in the volume of the affected tissues, accompanied by lymphorrhea. Patients keep showing a significant decrease in quality of life, limiting, among others, and sexual function. Surgical treatment is often associated with blood loss and postoperative infectious complications, especially for a large volume of the affected tissues. Lack of adequate compression therapy leads to a further increase is the cause of relapse. The aim of the study was to investigate the immediate and long-term results of treatment of patients with primary lymphedema of the external genitalia. We have been observed from 2001 to 2013 eight patients with primary lymphedema of the external genitalia, aged 14 to 52 years. Recurrent erysipelas and balanopostit occurred in 4 patients, 2 men at lymphorrhea, papillomatosis of the scrotal skin-one. The operation at the three men with primary lymphedema of the scrotum and penis and was a resection operation on the scrotum, and the circular excision of the prepuce, with one male surgical treatment was limited to a circular excision of the prepuce. One man in the postoperative period marked by necrosis of the skin of the penis, the year he was ndergone re-resection operation on the scrotum, resection of soft tissue of the penis. In connection with the formation of rough scar on the penis after 2 years of plastic surgery performed with excision of the scar and the formation of the penis, the displaced flap of the right iliac region. Other patients had no complications. Follow up results during one year was good. Conclusions: Primary lymphedema of genitalia is rare disease of in men in Russia. Surgical treatment of primary lymphedema of external genitalia require surgery in patients with a significant increase of the affected tissues, recurrent erysipelas in remission. As the preoperative preparation for large volumes of affected tissues is advisable to use a complex decongestive treatment. Bandaging of the scrotum and penis is nesessary immedieately after surgery. In the early postoperative period is necessary to continue, to the selection of medical compression hosiery with distributed pressure in the perineal area.
Article
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
Article
Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16-40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.
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The JFF has a lower rate of fistula and stricture than the ALT and RFF, allowing for early adjuvant therapy, a shorter hospital stay, a decreased risk of complications, and a quicker return to function. Importantly, the JFF has oral alimentation and speaking rates that are equivalent to the ALT and RFF. Despite the continued use of FC flaps for PLO reconstruction, improved knowledge with the harvest and use of the JFF has shown to be a viable alternative for circumferential PLO repair due to the benefits stated above
Chapter
Vascularized free lymph node transfer is an emerging physiologic innovative modification of an old surgical treatment for lymphedema. Despite some encouraging results, no consensus has been established neither upon the mechanism of physiology nor the selection criteria of the ideal candidate. Different donor areas have been proposed with discordant reports about the best donor lymph node area and the recipient area, whether proximal or distal. In this chapter, we describe in detail the technique of harvest of different proposed donor lymph nodes.
Chapter
This chapter first briefly talks about leg ulcers, which are the most common chronic wounds in developed countries affecting 1–3% of the British population. It then discusses lower limb trauma. The annual incidence of open lower limb fractures is approximately 5 per 100,000 population. Most common mechanisms of injury include: (i) Fall from height; (ii) Motor vehicle collision; and (iii) Interpersonal violence. A brief discussion of osteomyelitis, which is inflammation of bone caused by an infecting organism, is then presented. The discussion includes classification, mechanism of infection, pathology, investigation and treatment. The chapter also describes the pathogenesis, classification, staging, clinical diagnosis, and surgical management of lymphoedema. Finally it presents a brief discussion of pressure ulcers.
Article
Objetivo: Describir los aspectos más importantes del tratamiento del linfedema entendiéndose este desde la fisiopatología. Metodología: Se incluyeron artículos publicados en idiomas español e inglés, la mayoría entre 2011 y 2021 que tuvieran contenido relacionado con el objetivo del presente manuscrito. Conclusiones: El linfedema se ha convertido en un reto para los profesionales de la salud debido a su complejo tratamiento multidisciplinario, pero gracias al avance de la microcirugía, el manejo quirúrgico se convertido en una creciente alternativa efectiva, especialmente gracias a su enfoque fisiopatológico de la enfermedad. MÉD. UIS.2021;34(3): 61-70.
Article
Лимфедема (лимфостаз) – это врожденное или приобретенное патологическое состояние, развивающееся в результате нарушения оттока лимфы по лимфатическим капиллярам и периферическим лимфатическим сосудам конечностей и других органов, которое характеризуется локальным скопление жидкости, отечностью и прогрессирующими воспалительными изменениями кожи, приводящими к фиброзу и трофическим нарушениям. У взрослых основными причинами лимфедемы являются последствия различных травм или хирургических вмешательств, среди которых особое место занимает мастэктомия. Ниже мы приводим клинический случай первого в нашей практике применения аутотрансплантации кровоснабжаемых лимфатических узлов для лечения лимфедемы в комплексном лечении постмастэктомического синдрома, наряду с реконструкцией молочной железы. Lymphedema is a congenital or acquired pathologic condition that results from a disorder of the lymphatic system, with localized fluid retention and tissue swelling, characterized by a degenerative and inflammatory deterioration of the dermis and subdermis, resulting in diffuse, irreversible fibrosis. The main reasons of lymphedema in adults are trauma and surgical procedures. Mastectomy is the most common of them. Here we present a case of our first experience of vascularized lymph node transfer in treatment of postmastectomy patient with breast reconstruction.
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The use of CAD/CAM technology and 3D printed cutting guide offers – • significantly shorter operative time • precise and accurate reconstruction • better functional and aesthetic outcomes in patients who undergo mandibular reconstruction with free fibula flap. Based on literature review, available evidence and our experience, we recommend its use in all multi-segment fibular flaps for segmental mandibular reconstruction. Costs for CAD-CAM surgery is covered by gains in-  Surgical time,  Quality of reconstruction  Reduced complications
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Vascularized lymph node transfer (VLNT) has gained popularity over the last decade as a surgical treatment approach to chronic lymphedema. A flap containing lymph nodes is transplanted into an area of deficient lymphatic function to promote lymphangiogenesis, bridge the area of obstruction, and restore immunological function to the affected limb. VLNT to a lymphedematous extremity can significantly reverse the disease process while reducing its propensity for infection. In the upper extremity, it may also lead to improvement of brachial plexus neuropathies. When performed in appropriately selected patients, VLNT may obviate the need for lifelong massage therapy, compressive garments, and other supportive measures.
Article
Purpose Vascularized lymph node transfer is becoming more common in the treatment of lymphedema, but suitable small animal models for research are lacking. Here, we evaluated the feasibility of pedicled vascularized inguinal lymph node transfer in mice. Methods Twenty‐five mice were used in the study. An inguinal lymph node‐bearing flap with a vascular pedicle containing the superficial caudal epigastric vessels was transferred into the ipsilateral popliteal fossa after excision of the popliteal lymph node. Indocyanine green (ICG) angiography was used to confirm vascularity of the flap. ICG lymphography was performed to evaluate lymphatic flow at 3 and 4 weeks postoperatively. Patent blue dye was injected into the ipsilateral hind paw to observe staining of the transferred lymph node at 4 weeks postoperatively. All transferred lymph nodes were then harvested and histologically evaluated by hematoxylin and eosin staining. Results In 16 of the 25 mice, ICG lymphography showed reconnection between the transferred lymph node and the afferent lymphatic vessels, as confirmed by patent blue staining. Histologically, these transferred lymph nodes with afferent lymphatic reconnection significantly regressed in size (0.37 ± 0.24 mm²) and showed clear follicle formation, whereas those without afferent lymphatic reconnection showed less size regression (1.31 ± 1.17 mm²); the cell population was too dense to allow identification of follicles. Conclusions We established a mouse model of vascularized lymph node transfer with predictable afferent lymphatic reconnection. Both the vascularization and reconnection might be necessary for functional regeneration of the transferred lymph node.
Chapter
Over the years, many recent advances for diagnosis as well as treatment of lower limb edema have evolved. The current diagnostic tool indocyanine green lymphography (ICG-LG) can detect dermal lymph backflow in asymptomatic legs even at stage 0. At symptomatic stage ≥1, ultrasonography, magnetic resonance imaging-lymphography/computed tomography-lymphography (MRI-LG/CT-LG), and lymphoscintigraphy are also useful. Management includes modification of lifestyle and decompressive physiotherapy, which are mainstay of treatment. Medical management and surgical intervention are considered when the former fails and have limited role and are mostly optional some new therapies are also under trial which may prove to be of great benefit in the future. The goal of therapy is to restore function, reduce physical and psychological suffering, and prevent the development of abnormalities.
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Lymphaticovenular anastomosis (LVA) is an established supermicrosurgical treatment of lymphedema. The procedure is minimally invasive and conceptually simple. However, its reported outcome has been inconsistent. The inconsistency in outcome is likely related to surgical technique. In this chapter, the senior author (WFC) shares his experience of LVA, reviewing patient selection, surgery planning, the standard technique, and advanced technical maneuvers to improve surgical performance and the effectiveness of the procedure. We expect to equip this chapter’s readers with sufficient clinical and technical knowledge to not only start to perform the supermicrosurgical LVA but also achieve gratifying success with it.
Article
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Lymphedema is a chronic and progressive disease that affects many of the patients who underwent cancer ablative surgery and decreases the quality of life of them. Surgical management including lymphovenous shunting and vascularized lymph node transfer become popular in the field of microsurgery. For the better outcome of microsurgical approach to lymphedema, understanding of multiple image modalities is essential. Also, understanding other conservative management tools is crucial for setting reasonable algorism for lymphedema management.
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Patients undergoing autologous breast reconstruction have a higher satisfaction rate and perceived quality of life compared to patients undergoing implant-based breast reconstruction after mastectomy. Several inherent biases of the included studies however, mean that randomized controlled trials including patients eligible for both types of reconstruction are needed to verify and validate the findings. Similar data in Indian scenario is lacking and necessary to back this evidence and offer the best possible reconstructive options to our patients.
Book
Lymphedema: A Concise Compendium of Theory and Practice brings into one volume the most important sources of information to guide the evaluation and treatment of patients with lymphedema. The management of chronic lymphedema continues to challenge both patients and treating physicians worldwide. In the past decades, however, substantial progress has been achieved for both diagnosis and therapy of these disabling conditions. With increasing attention to the quality of life, this debilitating life-long disease is receiving more attention not only by lymphedema specialists, but also by clinicians across the spectrum of health care delivery. Lymphedema: A Concise Compendium of Theory and Practice provides clear, concise background and recommendations in an easy-to-use format. It is a valuable reference tool for clinical practitioners (physicians/nurse practioners/technicians) who wish to deliver state-of-the-art health care to their patients with lymphatic and venous disorders.
Article
Postoperative lymphedema after breast cancer surgery is a challenging problem. Recently, a novel microvascular lymph node transfer technique provided a fresh hope for patients with lymphedema. We aimed to combine this new method with the standard breast reconstruction. During 2008-2010, we performed free lower abdominal flap breast reconstruction in 87 patients. For all patients with lymphedema symptoms (n = 9), we used a modified lower abdominal reconstruction flap containing lymph nodes and lymphatic vessels surrounding the superficial circumflex vessel pedicle. Operation time, donor site morbidity, and postoperative recovery between the 2 groups (lymphedema breast reconstruction and breast reconstruction) were compared. The effect on the postoperative lymphatic vessel function was examined. The average operation time was 426 minutes in the lymphedema breast reconstruction group and 391 minutes in the breast reconstruction group. The postoperative abdominal seroma formation was increased in patients with lymphedema. Postoperative lymphoscintigraphy demonstrated at least some improvement in lymphatic vessel function in 5 of 6 patients with lymphedema. The upper limb perimeter decreased in 7 of 9 patients. Physiotherapy and compression was no longer needed in 3 of 9 patients. Importantly, we found that human lymph nodes express high levels of endogenous lymphatic vessel growth factors. Transfer of the lymph nodes and the resulting endogenous growth factor expression may thereby induce the regrowth of lymphatic network in the axilla. No edema problems were detected in the lymph node donor area. Simultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.
Article
Lymphedema complicating breast cancer treatment remains a challenging problem. The purpose of this study was to analyze the long-term results following microsurgical lymph node (LN) transplantation. Twenty-four female patients with lymphedema for more than 5 years underwent LN transplantation. They were treated by physiotherapy and resistant to it. LNs were harvested in the femoral region, transferred to the axillary region, and transplanted by microsurgical procedures. Long-term results were evaluated according to skin elasticity, decrease, or disappearance of lymphedema assessed by measurements, isotopic lymphangiography, and ability to stop physiotherapy. The postoperative period was uneventful; skin infectious diseases disappeared in all patients. Upper limb perimeter returned to normal in 10 cases, decreased in 12 cases, and remained unchanged in 2 cases. Five of 16 (31%) isotopic lymphoscintigraphies demonstrated activity of the transplanted nodes. Physiotherapy was discontinued in 15 patients (62.5%). Ten patients were considered as cured, important improvement was noted in 12 patients, and only 2 patients were not improved. LN transplantation is a safe procedure permitting good long-term results, disappearance, or a noteworthy improvement, in postmastectomy lymphedema, especially in the early stages of the disease.
Article
Objective: The abdominal and retroperitoneal lymphatic system is characterized by numerous anatomic variations. Our objective is to review MR lymphographic features of normal anatomy and abnormal conditions. Conclusion: MR lymphography is a noninvasive technique that is well suited for the examination of abdominal and retroperitoneal lymphatic vessels.
Les transferts lymphatiques.
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Becker C. Les transferts lymphatiques. Ann Chir Plast Esthet 2000.
Localized massive limphedema in morbidly obese patients.
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Batista BN, Doy A, Modolin ML, et al. Localized massive limphedema in morbidly obese patients. Rev Brá s Cir Plast 2009;4(Suppl 3):96.
Actual treatment of lymphedema.
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