Search Results (14)

Lymphedema is a chronic, incurable disease affecting patients who undergo high-risk cancer treatments. Advances in microsurgical techniques have paved the way for the development of techniques that can prevent or treat this unrelenting condition. In this article we discuss microsurgical interventions for the prevention and treatment of lymphedema, as well as the role of robotics in lymphatic surgery. Full article

Background: Lymphedema is a debilitating condition with high morbidity, yet despite advances in management, diagnostic ambiguity and fragmented referral patterns continue to delay appropriate care. We evaluated predictors of accurate diagnosis, microsurgical reconstruction candidacy, and secondary referrals generated during consultation with a lymphatic microsurgeon to highlight the need for a coordinated model of care. Methods: A retrospective chart review was performed for all outpatient referrals for ‘lymphedema’ from September 2020 to September 2021. Patient demographics, diagnostics, referral patterns, and lymphedema-related clinical data were collected. Results: 94 patients were referred for evaluation of possible lymphedema; lymphoscintigraphy confirmed diagnosis in 69. Following consultation, 23 patients received referrals for physical therapy, 17 for vascular surgery, and 8 for bariatric surgery or medical weight loss. Patients without lymphedema were more often referred to vascular surgery than those with lymphedema. Non-surgical candidates were more frequently referred to therapy or weight loss. Conclusions: Incorporating microsurgical reconstructive expertise into the evaluation of limb swelling improves diagnostic accuracy and refers patients- regardless of lymphedema status or surgical candidacy- to appropriate specialists. We propose a pathfinder model for patient flow that streamlines triage, improves access to accurate diagnosis and treatment, and prevents overburdening microsurgical practices with non-surgical patients. Full article

Lymphedema is a chronic, progressive, and debilitating disease of the lymphatic system with no current cure. Physiologic procedures, which address the underlying pathophysiology of lymphatic dysfunction, have gained traction in both treatment and prevention of lymphedema. This narrative review examines current physiologic lymphedema surgical techniques and emerging developments in this rapidly evolving field. While the two most common physiologic surgeries remain lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT), newer physiologic surgery techniques such as vascularized lymph vessel transfer (VLVT) and lymph node to vein anastomosis (LNVA) have been described in an effort to reduce donor site morbidity, with early promising clinical outcomes. The use of bioengineering with stem cells, pro-lymphangiogenic growth factors, and biomaterials such as Biobridge can be applied in conjunction with surgery to help promote lymphangiogenesis. Technological advances in robotic surgical systems and 3D exoscopes are helping to make supermicrosurgery more technically feasible and ergonomic, and increasing accessibility to lymphedema surgery. As our surgical armamentarium expands, treatment algorithms must be updated to determine how various surgical techniques can be combined and sequenced, how the indications for physiologic surgery can be expanded, and how surgical treatment can be tailored to the patient and disease process. Full article

Background/Objectives: Recent advancements in breast cancer treatment have led to increased survival rates, prompting a shift towards addressing breast cancer-related lymphedema (BCRL). Despite the evolving role of lymphatic surgery in breast reconstruction, there is limited literature evaluating the current role of lymphatic surgery in breast reconstruction. This review aims to evaluate the state of lymphatic surgery in breast reconstruction, analyzing surgical techniques and proposing a multi-institutional algorithmic approach. Methods: Through a search and screening of literature, data regarding the study type, type of operation (bypass, pLVB/ILR/LYMPHA, VLNT, or a combination of treatments), and clinical outcomes were collected. Results: The systematic review included 184 studies. Overall, the number of publications on lymphatic surgery increased from 4.4 per year (2010–2016) to 21.1 per year since 2017. The most published procedure was vascularized lymph node transfer (34.6%), followed by preventive lymphatic surgery (31.4%), therapeutic lymphovenous bypass (23.3%), and combined breast and lymphatic reconstruction (10.7%). While VLNT was the most published procedure, preventive surgery has been the most published topic since 2020, with 11.7 articles per year since. Similarly, there has been an increase in studies on combined lymphatic surgery and breast reconstruction in the last five years, with 16 articles published. Conclusions: The role of lymphatic surgery in breast cancer patients is evolving, with an increasing emphasis on preventive procedures and combined reconstructive approaches. However, our study shows that the current literature is predominantly based on lower-level evidence, highlighting the need for more randomized controlled trials to establish stronger clinical recommendations. Full article

Lymphedema surgeries have been proven effective in treating lymphedema and are not considered experimental or unproven. The medical literature consistently supports the safe and successful use of physiologic drainage lymphedema surgeries such as lymphaticovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and reductive surgeries such as suction-assisted protein lipectomy (SAPL) when performed by an experienced lymphedema surgery team to treat properly selected patients. Proper integration of lymphedema therapy is critical to achieving successful outcomes. We review effective lymphedema surgeries, their indications, patient selection, and the proper application of surgical treatments to achieve optimal results. Full article

Introduction: Reconstructive plastic surgeons have made great strides in the field of breast reconstruction to achieve the best results for patients undergoing treatment for breast cancer. As microsurgical techniques have evolved, these patients can benefit from additional treatment modalities to optimize the results of the reconstruction. Free tissue transfer from alternative donor sites for breast reconstruction is routinely performed, which was not possible in the past. Neurotization is now possible to address the numbness and lack of sensation to the reconstructed breast. For those patients who develop lymphedema of the upper extremity as a result of their breast cancer care, supermicrosurgical options are now available to treat and even to prevent the development of lymphedema. This study presents a narrative review regarding the latest microsurgical advancements in autologous free flap breast reconstruction. Methods: A literature review was performed on PubMed with the key words “autologous free flap breast reconstruction”, “deep inferior epigastric perforator flap”, “transverse upper gracilis flap”, “profunda artery perforator flap”, “superior gluteal artery perforator flap”, “inferior gluteal artery perforator flap”, “lumbar artery perforator flap”, “breast neurotization”, “lymphovenous bypass and anastomosis”, and “vascularized lymph node transfer”. Articles that specifically focused on free flap breast reconstruction, breast neurotization, and lymphedema surgery in the setting of breast cancer were evaluated and included in this literature review. Results: The literature search yielded a total of 4948 articles which were screened. After the initial screening, 413 articles were reviewed to assess the relevance and applicability to the current study. Conclusions: Breast reconstruction has evolved tremendously in recent years to provide the most natural and cosmetically pleasing results for those patients undergoing treatment for breast cancer. As technology and surgical techniques have progressed, breast cancer patients now have many more options, particularly if they are interested in autologous reconstruction. These advancements also provide the possibility of restoring sensibility to the reconstructed breast as well as treating the sequela of lymphedema due to their cancer treatment. Full article

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery. Full article

Primary lymphedema is a heterogeneous group of conditions encompassing all lymphatic anomalies that result in lymphatic swelling. Primary lymphedema can be difficult to diagnose, and diagnosis is often delayed. As opposed to secondary lymphedema, primary lymphedema has an unpredictable disease course, often progressing more slowly. Primary lymphedema can be associated with various genetic syndromes or can be idiopathic. Diagnosis is often clinical, although imaging can be a helpful adjunct. The literature on treating primary lymphedema is limited, and treatment algorithms are largely based on practice patterns for secondary lymphedema. The mainstay of treatment focuses on complete decongestive therapy, including manual lymphatic drainage and compression therapy. For those who fail conservative treatment, surgical treatment can be an option. Microsurgical techniques have shown promise in primary lymphedema, with both lymphovenous bypass and vascularized lymph node transfers demonstrating improved clinical outcomes in a few studies. Full article

Several different nosological classifications have been used over time for vascular malformations (VMs) since clinical and pathological signs are largely overlapping. In a large proportion of cases, VMs are generated by somatic mosaicism in key genes, belonging to a few different molecular pathways. Therefore, molecular characterization may help in the understanding of the biological mechanisms related to the development of pathology. Tissue biopsy is not routinely included in the diagnostic path because of the need for fresh tissue specimens and the risk of bleeding. Bypassing the need for bioptic samples, we took advantage of the possibility of isolating cell-free DNA likely released by the affected tissues, to molecularly characterize 53 patients by cfDNA-NGS liquid biopsy. We found a good match between the identified variant and the clinical presentation. PIK3CA variants were found in 67% of Klippel Trenaunay Syndrome individuals; KRAS variants in 60% of arteriovenous malformations; MET was mutated in 75% of lymphovenous malformations. Our results demonstrate the power of cfDNA-NGS liquid biopsy in VMs clinical classification, diagnosis, and treatment. Indeed, tailored repurposing of pre-existing cancer drugs, such as PIK3CA, KRAS, and MET inhibitors, can be envisaged as adjuvant treatment, in addition to surgery and/or endovascular treatment, in the above-defined VMs categories, respectively. Full article

The efficacy of lymphaticovenular anastomosis (LVA) for the treatment of primary lymphedema has been reported. Previous research suggested the efficacy of LVA on the anterior side of the lower limb, but no research has yet underlined the effectiveness of LVA on the posterior side. In the present study, we aimed to investigate the efficacy of LVA on the posterior side of the lower leg for treatment of primary lymphedema, i.e., whether further improvement of primary lower extremity lymphedema could be expected by performing LVA on the posterior side of the lower limb in addition to the LVA on the anterior side, which is usually performed. Forty-five patients with primary lower extremity lymphedema who underwent LVA twice between March 2018 and September 2020 were retrospectively investigated. Patients were classified into two groups: those who underwent LVA on the posterior side in the second operation (PoLVA group) and those who underwent LVA on the medial and anterior sides again in the second operation (MeLVA group). All patients underwent LVA on the medial and anterior sides in the first operation, but no sufficient improvement was observed. The following factors in the second operation were compared between the two groups: skin incision length, the number of anastomoses, the diameters of the lymphatic vessels, the time required for the dissection of the lymphatic vessels and veins and the reduction in volume. LVA resulted in 227 anastomoses (106 anastomoses in the PoLVA group and 121 anastomoses in the MeLVA group) in 26 patients with primary lymphedema of the lower extremities in two surgeries. The reduction in lower extremity lymphedema index was significantly greater in the PoLVA group than that in the MeLVA group (10.5 ± 4.5 vs. 5.5 ± 3.6; p = 0.008), and the number of anastomoses in the PoLVA group was significantly lower than that in the MeLVA group (3.5 ± 0.6 vs. 4.6 ± 1.0; p = 0.038). LVA on the posterior side subsequent to LVA on the medial and anterior sides resulted in the further improvement of primary lower extremity lymphedema with fewer numbers of anastomoses. Full article

Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement. Full article

Background: Excess lymphedematous tissue causes excessive oxidative stress in lymphedema. Lymphaticovenous anastomosis (LVA) supermicrosurgery is currently emerging as the first-line surgical intervention for lymphedema. No data are available regarding the changes in serum proteins correlating to oxidative stress and antioxidant capacity before and after LVA. Methods: A total of 26 patients with unilateral lower limb lymphedema confirmed by lymphoscintigraphy were recruited, and venous serum samples were collected before (pre-LVA) and after LVA (post-LVA). In 16 patients, the serum proteins were identified by isobaric tags for relative and absolute quantitation-based quantitative proteomic analysis with subsequent validation of protein expression by enzyme-linked immunosorbent assay. An Oxidative Stress Panel Kit was used on an additional 10 patients. Magnetic resonance (MR) volumetry was used to measure t limb volume six months after LVA. Results: This study identified that catalase (CAT) was significantly downregulated after LVA (pre-LVA vs. post-LVA, 2651 ± 2101 vs. 1448 ± 593 ng/mL, respectively, p = 0.033). There were significantly higher levels of post-LVA serum total antioxidant capacity (pre-LVA vs. post-LVA, 441 ± 81 vs. 488 ± 59 µmole/L, respectively, p = 0.031) and glutathione peroxidase (pre-LVA vs. post-LVA, 73 ± 20 vs. 92 ± 29 U/g, respectively, p = 0.018) than pre-LVA serum. In addition, after LVA, there were significantly more differences between post-LVA and pre-LVA serum levels of CAT (good outcome vs. fair outcome, −2593 ± 2363 vs. 178 ± 603 ng/mL, respectively, p = 0.021) and peroxiredoxin-2 (PRDX2) (good outcome vs. fair outcome, −7782 ± 7347 vs. −397 ± 1235 pg/mL, respectively, p = 0.037) in those patients with good outcomes (≥40% volume reduction in MR volumetry) than those with fair outcomes (<40% volume reduction in MR volumetry). Conclusions: The study revealed that following LVA, differences in some specific oxidative stress markers and antioxidant capacity can be found in the serum of patients with lymphedema. Full article

Introduction: Analysis of quality of life (QOL) outcomes is an important aspect of lymphedema treatment since this disease can substantially impact QOL in affected individuals. There are a growing number of studies reporting patient-reported outcomes (PROMs) for patients with lymphedema. The purpose of this study was to conduct a systematic review of outcomes and utilization of PROMs following surgical treatment of lymphedema. Methods: A literature search of four databases was performed up to and including March, 2019. Studies included reported on QOL outcomes after physiologic procedures, defined as either lymphovenous bypass (LVB) or vascularized lymph node transplant (VLNT), to treat upper and/or lower extremity primary or secondary lymphedema. Results: In total, 850 studies were screened—of which, 32 studies were included in this review. Lymphovenous bypass was the surgical intervention in 16 studies, VLNT in 11 studies, and both in 5 studies. Of the 32 total studies, 16 used validated survey tools. The most commonly used PROM was the lymph quality of life measure for limb lymphedema (LYMQOL) (12 studies). In the remaining four studies, the upper limb lymphedema 27 scale (ULL27), the short form 36 questionnaire (SF-36), the lymphedema functioning, disability and health questionnaire (Lymph-ICF), and lymphedema life impact scale (LLIS) were each used once. QOL improvement following surgical treatment was noted in all studies. Conclusions: Physiologic surgical treatment of lymphedema results in improved QOL outcomes in most patients. The use of validated PROM tools is increasing but there is no current consensus on use. Future research to evaluate the psychometric properties of PROMs in lymphedema is needed to guide the development and use of lymphedema-specific tools. Full article