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Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema

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Abstract

Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.

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References

  1. Cancer Facts & Figures (2011) American Cancer Society. Atlanta

  2. Kissin MW, Querci Della Rovere G, Easton D, Westbury G (1986) Risk of lymphedema following the treatment of breast cancer. Br J Surg 73:580e4

    Google Scholar 

  3. Mazeron JJ, Otmezguine Y, Huart J, Pierquin B (1985) Conservative treatment of breast cancer: results of management of axillary lymph node area in 3353 patients. Lancet 1:1387

    Article  CAS  PubMed  Google Scholar 

  4. Fleissig A, Fallowfield LJ, Langridge CI et al (2006) Post-operative arm morbidity and quality of life: results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat 95:279e93

    Article  Google Scholar 

  5. Langer I, Guller U, Berclaz G et al (2007) Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg 245:452e61

    Article  Google Scholar 

  6. Lucci A, McCall LM, Beitsch PD et al (2007) Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection compared with SLND alone in the American college of surgeons oncology group trial Z0011. J Clin Oncol 25:3657e63

    Article  Google Scholar 

  7. Veronesi U, Paganelli G, Viale G et al (2003) A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 349:546e53

    Article  Google Scholar 

  8. Ahmed RL, Prizment A, Lazovich D, Schmitz KH, Folsom AR (2008) Lymphedema and quality of life in breast cancer survivors: the Iowa women’s health study. J Clin Oncol 26(35):5689–5696

    Article  PubMed Central  PubMed  Google Scholar 

  9. Cohen SR, Payne DK, Tunkel RS (2001) Lymphedema: strategies for management. Cancer 92(Suppl):980–987

    Article  CAS  PubMed  Google Scholar 

  10. Zampell JC, Aschen S, Weitman ES, Yan A, Elhadad S, De Brot M, Mehrara BJ (2012) Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation. Plast Reconstr Surg 129:825–834

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  11. O’Brien BM, Khazanchi RK, Kumar PA et al (1989) Liposuction in the treatment of lymphedema: a preliminary report. Br J Plast Surg 42:530

    Article  PubMed  Google Scholar 

  12. Goldman A, Schavelzon DE, Blugerman GS (2002) Laserlipolysis: liposuction using Nd:YAG laser. Rev Soc Bras Cir Plast 17:17–26

    Google Scholar 

  13. Ichikawa K, Miyasaka M, Tanaka R, Tanino R, Mizukami K, Wakaki M (2005) Histologic evaluation of the pulsed Nd:YAG laser for laser lipolysis. Lasers Surg Med 36:43–46

    Article  PubMed  Google Scholar 

  14. Puckett CL (1983) Microlymphatic surgery for lymphedema. Clin Plast Surg 10:133–138

    CAS  PubMed  Google Scholar 

  15. Chen HC, O’Brien BM, Rogers IW et al (1990) Lymph node transfer for the treatment of obstructive lymphoedema in the canine model. Br J Plast Surg 43:578–586

    Article  CAS  PubMed  Google Scholar 

  16. Feng GM, Yang WG, Huang CH, Wang SY, Chen HC (2003) Lymph nodes transfer for treating mild to moderate limb lymphedema. JPSAROC 12:95–105

    Google Scholar 

  17. Becker C, Assouad J, Riquet M, Hidden G (2006) Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg 243:313–315

    Article  PubMed Central  PubMed  Google Scholar 

  18. Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC (2013) Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg

  19. Cordova A, D’Arpa S, Pirrello R et al (2009) Anatomic study on the transverse cervical vessels perforators in the lateral triangle of the neck and harvest of a new flap: the free supraclavicular transverse cervical artery perforator flap. Surg Radiol Anat 31:93–100

    Article  PubMed  Google Scholar 

  20. Lin CH, Ali R, Chen SC, Wallace C, Chang YC, Chen HC, Cheng MH (2009) Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg 123:1265–1275

    Article  CAS  PubMed  Google Scholar 

  21. Lim SY, Yeo MS, Nicoli F, Ciudad P, Constantinides J, Kiranantawat K, Sapountzis S, Chung-Wai Ho A, Chen HC (2014) End-to-patch anastomosis for microvascular transfer of free flaps with small pedicle. J Plast Reconstr Aesthet Surg Dec 9.

  22. Ciudad P, Yeo MS, Sapountzis S, Lim SY, Nicoli F, Maruccia M, Kiranantawat K, Chen HC (2014) Microsurgical debulking procedure after free lymph node flap transfer. Microsurgery 34:670–1.20

    Article  PubMed  Google Scholar 

  23. Stanton AW, Holroyd B, Mortimer PS, Levick JR (1999) Comparison of microvascular filtration in human arms with and without postmastectomy oedema. Exp Physiol 84:405–419

    Article  CAS  PubMed  Google Scholar 

  24. Bates DO, Levick JR, Mortimer PS (1994) Starling pressures in the human arm and their alteration in postmastectomy oedema. J Physiol 477(Pt 2):355–363

    Article  PubMed Central  PubMed  Google Scholar 

  25. Roberts CC, Stanton AW, Pullen J, Bull RH, Levick JR, Mortimer PS (1994) Skin microvascular architecture and perfusion studied in human postmastectomy oedema by intravital video-capillaroscopy. Int J Microcirc Clin Exp 14:327–334

    Article  CAS  PubMed  Google Scholar 

  26. O’Brien BM, Sykes P, Threlfall GN, Browing FS (1977) Microlymphaticovenous anastomoses for obstructive lymphedema. Plast Reconstr Surg 60:197–211

    Article  PubMed  Google Scholar 

  27. Medgyesi S (1983) A successful operation for lymphoedema using a myocutaneous flap as a “wick”. Br J Plast Surg 36:64–66

    Article  CAS  PubMed  Google Scholar 

  28. Slavin SA et al (1997) An investigation of lymphatic function following free‐tissue transfer. Plast Reconstr Surg 99:730–741

    Article  CAS  PubMed  Google Scholar 

  29. Yan A et al (2011) Mechanisms of lymphatic regeneration after tissue transfer. PLoS ONE 6(2):e17201

  30. Honkonen KM, Visuri MT, Tervala TV, Halonen PJ, Koivisto M, Lähteenvuo MT, Alitalo KK, Ylä-Herttuala S, Saaristo AM (2013) Lymph node transfer and perinodal lymphatic growth factor treatment for lymphedema. Ann Surg 257:961–967

    Article  PubMed  Google Scholar 

  31. Brorson H, Svensson H (1998) Liposuction combined with controlled compression therapy reduces arm lymphoedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 102:1058

    Article  CAS  PubMed  Google Scholar 

  32. Brorson H, Svensson H, Norrgren K, Thorsson O (1998) Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology 31:156–172

    CAS  PubMed  Google Scholar 

  33. Stanton AW, Modi S, Bennett Britton TM, Purushotham AD, Peters AM, Levick JR, Mortimer PS (2009) Breast Cancer Res Treat 117:549–557

    Article  PubMed  Google Scholar 

  34. Hadamitzky C, Blum KS, Pabst R (2009) Regeneration of autotransplanted avascular lymph nodes in the rat is improved by platelet-rich plasma. J Vasc Res 46:389–396

    Article  PubMed  Google Scholar 

  35. Sapountzis S, Ciudad P, Lim SY, Chilgar RM, Kiranantawat K, Nicoli F, Constantinides J, Wei MY, Sönmez TT, Singhal D, Chen HC (2014) Modified Charles procedure and lymph node flap transfer for advanced lower extremity lymphedema. Microsurgery 34:439–447

    Article  PubMed  Google Scholar 

  36. Sapountzis S, Nicoli F, Chilgar R, Ciudad P (2013) Evidence-based analysis of lymph node transfer in postmastectomy upper extremity lymphedema. Arch Plast Surg 40:450–451

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

This research was supported by the National Ministry of Health and Welfare of Taiwan under Grant MOHW-TD-M-111-7. Moreover, the authors thank NeoAsia Ltd. Taipei (Taiwan) for technical support during this study.

Conflict of interest

The authors have no relevant financial interest in this article.

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Authors and Affiliations

  1. Department of Plastic and Reconstructive Surgery, China Medical University Hospital, 2 Yuh-Der Road, 40447, Taichung, Taiwan

    Fabio Nicoli, Joannis Constantinides, Pedro Ciudad, Stamatis Sapountzis, Kidakorn Kiranantawat, Seong Yoon Lim, Matthew Sze-Wei Yeo, Ram M. Chilgar & Hung-Chi Chen

  2. Department of Plastic and Reconstructive Surgery, University of Rome “Tor Vergata”, Rome, Italy

    Fabio Nicoli & Marzia Nicoli

  3. Department of Plastic and Reconstructive Surgery, St. Thomas’ Hospital, London, UK

    Joannis Constantinides

  4. Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

    Kidakorn Kiranantawat

  5. Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, Italy

    Davide Lazzeri & Marzia Nicoli

  6. Department of Pathology, China Medical University Hospital, Taichung, Taiwan

    Pei-Yu Chen

  7. Department of Plastic and Reconstructive Surgery, Maharashtra University of Health Sciences, Nashik, India

    Ram M. Chilgar

Authors
  1. Fabio Nicoli
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  2. Joannis Constantinides
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  3. Pedro Ciudad
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  4. Stamatis Sapountzis
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  5. Kidakorn Kiranantawat
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  6. Davide Lazzeri
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  7. Seong Yoon Lim
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  8. Marzia Nicoli
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  9. Pei-Yu Chen
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  10. Matthew Sze-Wei Yeo
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  11. Ram M. Chilgar
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  12. Hung-Chi Chen
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Corresponding author

Correspondence to Hung-Chi Chen.

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Nicoli, F., Constantinides, J., Ciudad, P. et al. Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema. Lasers Med Sci 30, 1377–1385 (2015). https://doi.org/10.1007/s10103-015-1736-3

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  • DOI: https://doi.org/10.1007/s10103-015-1736-3

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