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Massive localized lymphedema of the mons: the pi-cut technique

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Abstract and Figures

Massive localized lymphedema (MLL) is a form of secondary lymphedema caused by obstruction of lymphatic flow seen in morbidly obese patients. Common areas for the large mass include the abdomen, suprapubic region, scrotum, and thigh. Skin changes and the sheer size cause significant morbidity. Described as a benign lymphoproliferative overgrowth, MLL if left untreated can progress to angiosarcoma. The key to resection is minimizing blood loss and the key to reconstruction is to reconstruct utilizing the principles of vulvar esthetic subunits. For hemostasis, a tourniquet is used around the base of the mass and infiltration with wetting solution is injected. Reconstruction with the “pi-cut” technique, so named because of its resemblance to the mathematical symbol of pi, allows closure along the vulvar esthetic subunits. To illustrate our surgical technique, we present a case of MLL of the mons veneris in a 53-year-old woman with a BMI (body mass index) of 78 kg/m2. The specimen weighed approximately 17.5 kg, the heaviest MLL of the mons veneris described in the literature. Our resection technique and pi-cut closure technique allowed for minimal blood loss and postoperative morbidity and an esthetic closure respecting the vulvar esthetic subunits. MLL of the mons veneris can be successfully and safely resected with an esthetic result using our technique. Level of Evidence: Level V, therapeutic study.
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IDEAS AND INNOVATIONS
Massive localized lymphedema of the mons: the pi-cut technique
Hubert B. Shih
1
&Rahim Nazerali
1
&Anandev Gurjala
1
&Leila Jazayeri
1
&
Gordon K. Lee
1
Received: 31 July 2016 /Accepted: 26 December 2016 /Published online: 16 January 2017
#Springer-Verlag Berlin Heidelberg 2017
Abstract Massive localized lymphedema (MLL) is a form of
secondary lymphedema caused by obstruction of lymphatic
flow seen in morbidly obese patients. Common areas for the
large mass include the abdomen, suprapubic region, scrotum,
and thigh. Skin changes and the sheer size cause significant
morbidity. Described as a benign lymphoproliferative over-
growth, MLL if left untreated can progress to angiosarcoma.
The key to resection is minimizing blood loss and the key to
reconstruction is to reconstruct utilizing the principles of vulvar
esthetic subunits. For hemostasis, a tourniquet is used around
the base of the mass and infiltration with wetting solution is
injected. Reconstruction with the Bpi-cut^technique, so named
because of its resemblance to the mathematical symbol of pi,
allows closure along the vulvar esthetic subunits. To illustrate
our surgical technique, we present a case of MLL of the mons
veneris in a 53-year-old woman with a BMI (body mass index)
of 78 kg/m2. The specimen weighed approximately 17.5 kg,
the heaviest MLL of the mons veneris described in the litera-
ture. Our resection technique and pi-cut closure technique
allowed for minimal blood loss and postoperative morbidity
and an esthetic closure respecting the vulvar esthetic subunits.
MLL of the mons veneris can be successfully and safely
resected with an esthetic result using our technique.
Level of Evidence: Level V, therapeutic study.
Keywords Lymphedema .Obesity .Morbid .Reconstructive
surgical procedures
Introduction
Massive localized lymphedema (MLL) is a benign over-
growth of lymphoproliferative tissue and a known complica-
tion of morbid obesity. The etiology has not been totally de-
fined, but it is thought to be due to mechanical alterations in
lymph drainage due to obesity leading to lymphedema [1].
First described by Farshid and Weiss in 1998, it was termed
massive localized lymphedema due to the clinical presentation
and morphology. The lesion was noted to be histologically
similar to well-differentiated liposarcoma; hence, the term
pseudosarcoma is occasionally used [2].
Patients with MLL usually present with a large painless
mass that has been slowly growing for several years.
Ultimately, the size causes significant functional limitations.
The thickened, woody, and excoriated skin can also cause
significant morbidity including chronic wounds and infec-
tions. In 2013, Chopra et al. surveyed all the MLL cases pre-
sented in the literature and found the average BMI to be 61 kg/
m2 with the most common location being the thigh. Other
common areas include the lower abdomen, the mons, and
the scrotum. The mons is unique in that reconstruction after
resection needs to take into account the vulvar esthetics. The
technique proposed here offers resection with key attention to
minimizing blood loss, and the reconstruction method re-
spects the vulvar subunits. A case utilizing these principles
is presented. Overall, five cases of MLL of the mons are re-
ported in the literature; the case presented here is the heaviest
specimen from a female on record [3].
Surgical technique
Because patients with MLL suffer from a severe reduction in
quality of life and problems with hygiene, as well as concerns
*Hubert B. Shih
hshih@stanford.edu
1
Department of Surgery, Division of Plastic and Reconstructive
Surgery, Stanford Hospital and Clinics, 770 Welch Road, Suite 400,
Palo Alto, CA 94304, USA
Eur J Plast Surg (2017) 40:343346
DOI 10.1007/s00238-016-1270-y
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