Lymphatic Patterns in the Superficial Circumflex Iliac Artery Perforator Flap.

BACKGROUND: Lymphedema is a chronic condition, characterized by fluid buildup and tissue swelling and is caused by impairment of the lymphatic system. The lymph interpositional flap transfer technique, in which lymph flow is restored with a flap that includes subdermal lymphatic channels, is an option for surgical reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap can be used for this purpose. This study aimed to describe and characterize the lymphatic patterns within the vascular territory of the SCIP flap. METHODS: This cross-sectional multicenter study involved 19 healthy volunteers aged ≥18 years of both sexes assessing the bilateral SCIP flap zone. Superficial lymphatic patterns were evaluated at 4-, 14-, and 24 minutes after indocyanine green (ICG) lymphography injection. Standardized procedures were implemented for all participants in both hospitals. RESULTS: The linear pattern was predominant bilaterally. The median number of lymphatic vessels and their length increased over time. Most lymphatic vessels in the SCIP flap were oriented toward the inguinal lymph node (ILN). However, the left SCIP zone lymphatic vessels were directed opposite to the ILN. CONCLUSION: The two sides SCIP zones were not significantly different. The primary direction of the bilateral lymphatic vessels was toward the ILN, although only single-side lymphatic vessels were in the opposite direction. These findings emphasize the importance of assessing lymphatic axiality and coherent lymphatic patterns prior to undertaking the SCIP as an interposition flap, to ensure effective restoration of lymphatic flow.

Temporal validation of a risk prediction model for breast cancer-related lymphoedema in European population: A retrospective study.

AIMS: To perform temporal validation of a risk prediction model for breast cancer-related lymphoedema in the European population. DESIGN: Temporal validation of a previously developed prediction model using a new retrospective cohort of women who had undergone axillary lymph node dissection between June 2018 and June 2020. METHODS: We reviewed clinical records to identify women who did and did not develop lymphoedema within 2 years of surgery and to gather data regarding the variables included in the prediction model. The model was calibrated by calculating Spearman's correlation between observed and expected cases. Its accuracy in discriminating between patients who did versus did not develop lymphoedema was assessed by calculating the area under the receiver operating characteristic curve (AUC). RESULTS: The validation cohort comprised 154 women, 41 of whom developed lymphoedema within 2 years of surgery. The value of Spearman's coefficient indicated a strong correlation between observed and expected cases. Sensitivity of the model was higher than in the derivation cohort, as was the value of the AUC. CONCLUSION: The model shows a good capacity to discriminate women at risk of lymphoedema and may therefore help in developing improved care pathways for individual patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Identifying risk factors for lymphoedema secondary to breast cancer treatment is vital given its impact on women's physical and emotional well-being. IMPACT: What problem did the study address? Risk of BCRL. What were the main findings? The prediction model has a good capacity to discriminate women at risk of lymphoedema. Where and on whom will the research have an impact? In clinical practice with women at risk of BCRL. REPORTING METHOD: STROBE checklist. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: It presents a validated risk prediction model for BCRL. NO PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution in the conduct of this study.

Chimeric SCIP flap with iliac bone for reconstruction of foot first ray in a radiated surgical bed: A case report.

Surgical management of sarcoma has evolved from amputation to limb salvage. Nevertheless, subsequent resections in previously irradiated feet are still challenging to reconstruct. First foot ray functional reconstruction is relevant due to its function in weight-bearing and gait. The reconstruction should include a thin, pliable and non-shearing skin paddle with vascularized long cortical bone to mimic the first metatarsal. A clinical case of a 37-year-old patient with a second sarcoma recurrence of the first metatarsal is presented. The patient was irradiated before this new recurrence and had a previous reconstruction with fibula allograft, but subsequently developed a first metatarsal pseudoarthrosis. A wide resection was performed (3.5 cm bone defect) and immediate soft tissue and bone reconstruction with a chimeric SCIP flap with a 17 × 8 cm skin paddle and 3.5 × 1.5 cm iliac bone (cSCIP-IB). At 7 months post-operatively, the patient was able to resumed full weight-bearing. Three years later, remains without disease progression. CSCIP-IB is a good option for foot first ray reconstruction in irradiated beds. This flap has low donor site morbidity and a higher ossification success rate compared to bone allografts.

Consensus Conference Statement on the General Use of Near-infrared Fluorescence Imaging and Indocyanine Green Guided Surgery: Results of a Modified Delphi Study.

BACKGROUND: In recent decades, the use of near-infrared light and fluorescence-guidance during open and laparoscopic surgery has exponentially expanded across various clinical settings. However, tremendous variability exists in how it is performed. OBJECTIVE: In this first published survey of international experts on fluorescence-guided surgery, we sought to identify areas of consensus and nonconsensus across 4 areas of practice: fundamentals; patient selection/preparation; technical aspects; and effectiveness and safety. METHODS: A Delphi survey was conducted among 19 international experts in fluorescence-guided surgery attending a 1-day consensus meeting in Frankfurt, Germany on September 8th, 2019. Using mobile phones, experts were asked to anonymously vote over 2 rounds of voting, with 70% and 80% set as a priori thresholds for consensus and vote robustness, respectively. RESULTS: Experts from 5 continents reached consensus on 41 of 44 statements, including strong consensus that near-infrared fluorescence-guided surgery is both effective and safe across a broad variety of clinical settings, including the localization of critical anatomical structures like vessels, detection of tumors and sentinel nodes, assessment of tissue perfusion and anastomotic leaks, delineation of segmented organs, and localization of parathyroid glands. Although the minimum and maximum safe effective dose of ICG were felt to be 1 to 2 mg and >10 mg, respectively, there was strong consensus that determining the optimum dose, concentration, route and timing of ICG administration should be an ongoing research focus. CONCLUSIONS: Although fluorescence imaging was almost unanimously perceived to be both effective and safe across a broad range of clinical settings, considerable further research remains necessary to optimize its use.

Multidisciplinary preventive intervention for breast cancer-related lymphedema: An international consensus.

OBJECTIVE: To establish a consensus regarding the multidisciplinary prevention of breast cancer-related lymphedema (BCRL), taking into account the expert opinion of professional groups from across the world involved in the identification and treatment of breast cancers. METHODS: International consensus study involving a modified nominal group and Delphi process. A total of 50 preventive strategies representing those used by a range of health disciplines involved in breast cancer care were identified by the nominal group. These strategies were categorised into four subgroups (general recommendations, therapeutic approach, rehabilitation medicine and physiotherapy and dietary recommendations) and presented in survey format to a multidisciplinary panel of experts in a two-round Delphi process. Eleven specialist areas and 15 countries were represented on the panel. RESULTS: Twenty-seven experts responded to both Delphi rounds, and the mean overall agreement after Round 2 was 85.7%. Of the 50 proposed strategies for preventing BCRL, 48 yielded consensus among experts. CONCLUSION: We report an international consensus for the multidisciplinary prevention of BCRL, setting out recommendations aimed at systematising the care of women with breast cancer. The consensus could provide a platform for the development of standardised clinical guidelines.

Breast cancer-related lymphoedema: Risk factors and prediction model.

AIMS: To identify the risk factors for lymphoedema following axillary lymph node dissection (ALND) in a European sample and to propose a lymphoedema prediction model for this population. DESIGN: Predictive retrospective cohort study comparing women who developed lymphoedema in 2 years of undergoing ALND with those who did not developed lymphoedema. METHODS: We reviewed the clinical records of 504 women who, between January 2008 and May 2018, underwent surgery for breast cancer that involved ALND. Logistic regression was used to identify significant risk factors for lymphoedema. The prediction accuracy of the model was assessed by calculating the area under the receiver operating characteristic curve. RESULTS: Of the 504 women whose records were analysed, 156 developed lymphoedema. Significant predictors identified in the regression model were level of lymph node dissection, lymph node status, post-operative complications, body mass index (BMI) and number of lymph nodes extracted. The prediction model showed good sensitivity (80%) in the study population. CONCLUSIONS: The factor contributing most to the risk of lymphoedema was the level of lymph node dissection, and the only patient-related factor in the prediction model was BMI. The model offers good predictive capacity in this population and it is a simple tool that breast care units could use to assess the risk of lymphoedema following ALND. Nurses with specialist knowledge of lymphoedema have a key role to play in ensuring that women receive holistic and individualized care. IMPACT: What problem did the study address? Secondary lymphoedema is one of the main complications in the treatment of breast cancer. What were the main findings? The prediction model included five factors associated with the risk of lymphoedema following ALND. The strongest predictor was the level of lymph node dissection, and the only patient-related factor was BMI. Where and on whom will the research have an impact? The prediction model offers breast care units a tool for assessing the risk of lymphoedema in women undergoing surgery involving ALND. The results highlight the importance of weight reduction as a preventive measure and support a more conservative surgical approach.

Ankle joint salvage surgery with an ipsilateral mid-fibula osteocutaneous free flap and contralateral anterolateral thigh free flap: A case report and literature review.

The tibiofibular joint can be reconstructed after distal fibular sarcoma salvage surgery to maintain ankle stability and achieve early gait. Classical reconstructive options include ligamentoplasties, arthrodesis, prosthetic replacement, bone grafts, and pedicled ipsilateral or free contralateral fibular bone flaps. We present a novel strategy for reconstruction of the ankle in an elderly patient and a literature review. A 68-year-old man presented with a high-grade myxofibrosarcoma to his distal fibula. Wide resection of the tumor and adjacent structures left a 12 × 12 × 8 cm defect including the distal fibula (10 cm), a 2 cm fragment of the lateral cortex of the tibia, the lateral anterior and superficial posterior compartments, and the lateral compartment. A 3 cm distal fibula remnant was left in the ankle mortice. Reconstruction was performed using a free ipsilateral 13-cm diaphyseal osteocutaneous fibular flap telescoped into the distal fibula remnant and anastomosed to the anterior tibial artery. A pre-bent L-shaped locking plate was used to reconstruct a syndesmotic joint. A 21 × 13 cm suprafascial ALT flap was anastomosed to the proximal stump of the peroneal artery to cover the soft tissue defect. The patient had no complications and was ambulating with full weight bearing by postoperative week 11. He received postoperative chemo and radiotherapy. Three years postoperatively, he is tumor free, has complete ankle ROM and stability, and ambulates with no restrictions. Limb sparing surgery with a functional tibiofibular joint reconstruction should be considered to attain an early functional recovery after distal fibula sarcomas resection.

The largest multicentre data collection on prepectoral breast reconstruction: The iBAG study.

BACKGROUND AND OBJECTIVES: In the last years, prepectoral breast reconstruction has increased its popularity, becoming a standard reconstructive technique by preserving pectoralis major anatomy and functionality. Nevertheless, the lack of solid and extensive data negatively impacts on surgeons' correct information about postoperative complication rates and proper patient selection. This study aims to collect the largest evidence on this procedure. METHODS: A multicentre retrospective audit, promoted by the Barcelona Hospital, collected the experience of 30 centers on prepectoral breast reconstruction with Braxon ADM. The study had the scientific support of INPECS and IIB societies which provided the online database Clinapsis. RESULTS: A total of 1450 procedures were retrospectively collected in a 6-year period. Mean age 52.4 years, BMI 23.9, follow-up 22.7 months. Reconstruction was carried out after a tumor in 77.1% of the cases, 20.1% had prophylactic surgery, 2.8% had revisions. Diabetes, smoke, and immunosuppression had an influence on complications occurrence, as well as implant weight. Capsular contracture was associated with postoperative radiotherapy, but the overall rate was low (2.1%). Complications led to implant loss in 6.5% of the cases. CONCLUSIONS: The international Braxon Audit Group multicentre data collection represents a milestone in the field of breast reconstruction, extensively improving the knowledge on this procedure.

Summary of hands-on supermicrosurgery course and live surgeries at 8th world symposium for lymphedema surgery.

The hands-on supermicrosurgery course provided participants a valuable learning experience of in-depth practices of supermicrosurgical skills with experts. Seven live surgeries were successfully demonstrated at 8th World Symposium for Lymphedema Surgery. Variable donor sites for vascularized lymph node transfer were the submental, supraclavicular, groin, and omental; while the recipient sites included the wrist and axilla in upper limb; and popliteal and groin in the lower limb. The therapeutic and preventive lymphovenous anastomosis was also satisfactorily performed.

Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report.

Reconstruction of thigh defects is usually straightforward, but in cases of poor soft tissue quality, free flap reconstruction is not possible due to the absence of recipient vessels. The turbocharge technique may increase the viable, vascularized area of a flap. In this report we present a case of the use of a turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels. A 29-year-old woman who underwent neoadjuvant chemotherapy plus radiation therapy for a leiomyosarcoma on the left thigh. Six weeks later, complete tumor excision and a femoropopliteal bypass with contralateral saphenous vein was performed. In the following days the wound had dehiscence, infection, necrosis of the surrounding muscles and exposure of femoropopliteal bypass. No recipient vessels were available for free flap and critical limb ischemia due to bypass thrombosis was detected. The reconstruction of a large thigh defect (30 × 12 cm) and the coverage of a femoropopliteal bypass with a turbocharged bilateral pedicled DIEP flap was performed. A flap including the entire infraumbilical tissue was designed and the anastomosis of the proximal stump of the right inferior epigastric vessels with the distal ends of the inferior left epigastric vessels was performed to increase the viable area. The flap survived without any complications during the postoperative period. At 12-month follow up, coverage was stable with no tumor recurrence. Our result suggests that a turbocharged bilateral pedicled DIEP flap may be an option for reconstructing large tissue defects when no recipient vessels are available for free flap.

The Supraclavicular Artery Perforator Flap: A Comparative Study of Imaging Techniques Used in Preoperative Mapping.

BACKGROUND: The supraclavicular artery flap is an excellent flap for head and neck reconstruction. The aim of this study is to assess imaging techniques to define the precise vascular boundaries of this flap. METHODS: Six imaging techniques were used for supraclavicular artery mapping in 65 cases; handheld Doppler, triplex ultrasound, computed tomography angiography, magnetic resonance angiography, digital subtraction angiography, and indocyanine green angiography. We checked the site of the perforators, the course of a supraclavicular artery, and anatomical mapping of the supraclavicular artery. RESULTS: Handheld Doppler identified perforators' sites in 80% of the cases but showed no results for the course of the vessel. Triplex ultrasound identified the site of perforators in 52.9%, and partial mapping of the course of a supraclavicular artery in 64.7% of the cases. Computerized tomography angiography showed the site of perforators in 60%, and the course of supraclavicular artery completely in 45%, and partially in an additional 30%of the cases examined. Magnetic resonance angiography showed negative results for all parameters. Digital subtraction angiography showed the partial course of a supraclavicular artery in 62.5%, but showed no perforators. Indocyanine green angiography showed the site of perforators in 60% and a partial course of supraclavicular artery distal to perforators in 60%.Anatomical mapping of the vessel was possible with computerized tomography angiogram completely in 45%, and partially in 30%, and was also possible with indocyanine green angiography partially in 60%. CONCLUSION: Computerized tomography angiography showed best results in the mapping of the supraclavicular artery, but with an inability to define the perforator perfusion territories, and also with risks of irradiation, while indocyanine green angiography is a good alternative as it could precisely map the superficial course of the artery and angiosomes, with no radiation exposure.

Intratissue lymphovenous communications in the mechanism of action of vascularized lymph node transfer.

BACKGROUND AND OBJECTIVES: Vascularized lymph node transfer (VLNT) as a surgical treatment for cancer-related lymphedema has shown beneficial effects. The mechanism of action of this procedure involves lymphangiogenesis and lymphovenous communications (LVC) within the lymph nodes. We propose intratissue LVC as an additional element responsible for drainage of lymph to blood in the flap and examine this hypothesis in the current study. METHODS: This prospective study determined the passage of lymph to the venous system via intratissue LVC in 26 free flaps used for breast reconstruction. We evaluated whether fluorescence was positive in the pedicle vein after increasing time intervals following intradermal injection of indocyanine green (ICG) dye into the flaps using near infra-red fluorescence lymphography. RESULTS: We studied 26 free flaps, 22 deep inferior epigastric perforator (DIEP) flaps (84.6%), and 4 superior gluteal artery perforator (SGAP) flaps (15.4%). Fluorescence in the pedicle vein was positive in 22 of the 26 flaps (P = 0.000). The median time for fluorescence evaluation in the pedicle vein was 120 min. CONCLUSIONS: Fluorescence in the pedicle vein after ICG intradermal injection indicates functional intratissue LVC in free flaps. J. Surg. Oncol. 2017;115:27-31. © 2016 Wiley Periodicals, Inc.

The 5th world symposium for lymphedema surgery-Recent updates in lymphedema surgery and setting up of a global knowledge exchange platform.

The successful completion of the 5th World Symposium for Lymphedema Surgery (WSLS) marks another milestone in the development and advancement of the management of lymphedema. We present our experience in organizing such a scientific lymphedema conference as well as a summary of seven variable live surgeries used for treating lymphedema. An update of current knowledge and determination of future direction in the treatment of lymphedema was made possible via WSLS 2016. J. Surg. Oncol. 2017;115:6-12. © 2016 Wiley Periodicals, Inc.

Evaluation of the effectiveness of the prepectoral breast reconstruction with Braxon dermal matrix: First multicenter European report on 100 cases.

We report the outcomes of the European prospective study on prepectoral breast reconstruction using preshaped acellular dermal matrix for complete breast implant coverage. Seventy-nine patients were enrolled between April 2014 and August 2015 all over Europe using a single protocol for patient selection and surgical procedure, according to the Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guidelines for the use of acellular dermal matrix in breast surgery. The preshaped matrix completely wraps the breast implant, which is placed above the pectoralis major, without detaching the muscle. A total of 100 prepectoral breast reconstructions with complete implant coverage were performed. This series, with mean follow-up of 17.9 months, had two cases of implant loss (2.0%) including one necrosis of the nipple and one wound breakdown (1.0% respectively). No implant rotations were observed. Good cosmetic outcomes were obtained with natural movement of the breasts and softness to the touch; none of the patients reported experiencing pain or reduction in the movements of the pectoralis major muscle postoperatively. The use of preshaped acellular dermal matrix for a complete breast implant coverage in selected patients is safe and gives satisfactory results, both from the aesthetic view point and the low postoperative complication rates. Further studies reporting long-term outcomes are planned.

A comprehensive review of the natural lymphaticovenous communications and their role in lymphedema surgery.

Cancer-related lymphedema is a progressive, chronic condition that impairs quality of life. Its pathophysiology and the mechanisms of action of current reconstructive surgical treatments are not fully understood but lymphaticovenous communications may play a key role. We review the available literature on lymphaticovenous communications and their implications in lymphedema surgery, and propose a subclassification of lymphaticovenous communications. J. Surg. Oncol. 2016;113:374-380. © 2016 Wiley Periodicals, Inc.

Barcelona Lymphedema Algorithm for Surgical Treatment in Breast Cancer-Related Lymphedema.

Background Breast cancer-related lymphedema is a prevalent condition that has a major impact on quality of life. Surgical treatment has become an alternative to help affected patients with good results. However, there is no consensus on surgical procedure and protocol. Methods We analyzed our data in two periods: from June 2007 to December 2011 and from January 2012 to June 2014. Data included the analysis of the limb circumferences and the subjective symptoms felt by patients. Results Of the 200 patients treated in the study, 81 had lymphaticovenous anastomosis, 7 had autologous lymph node transfer, 16 had total breast anatomy restoration, 52 had vibroliposuction, and 44 had combined reconstructive procedures. In the first period, the circumference of the superior limb showed a decrease of 0.9 to 6.1 cm (average 2.75 cm). In the second period, the circumference of the superior limb showed a decrease of 2.9 to 6.1 cm (average 3.85 cm). Clinical results and data from the questionnaires confirmed the improvement and subjective benefits. Conclusion We have obtained considerable improvements in results of limb circumferences and subjective symptoms after incorporating several modifications into our surgical strategy for lymphedema treatment. A detailed preoperative assessment should be performed to determine whether reconstructive surgery or palliative surgery is indicated.

Combined Surgical Treatment in Breast Cancer-Related Lymphedema.

BACKGROUND: Lymphedema is a well-known sequela of breast but no consensus has been reached about the ideal treatment. Surgical approaches, however, are receiving increased attention. Various microsurgical reconstructive techniques aim to restore anatomy and function of the lymphatic system in upper limb breast cancer-related lymphedema (BCRL). We combined two techniques, lymphaticovenous anastomosis (LVA) and autologous lymph node transplantation (ALNT) after carefully selecting those who may benefit from the surgery. We called this the "combined surgical treatment (CST)" approach. METHODS: From June 2007 to December 2011, we performed CST in 106 patients with upper limb BCRL. Clinical evaluation and diagnostic imaging studies were performed preoperatively in all the patients. CST was offered to patients with stage I/II lymphedema, according to the criteria of the International Society of Lymphology (ISL). RESULTS: Overall 59 of the 106 patients underwent LVA, 7 underwent ALNT, and 40 underwent both the techniques. All 47 lymph node (LN)-flaps survived but 11 (22%) required surgical revision within 3 days. A total of 21 LN-flaps (45%) showed no radiotracer uptake at 1 year. Around 1 to 7 LVAs for each patient (average 3.4) were performed. Preoperative versus postoperative excess circumference decreased between 12 and 86.7% (average 39.72%). Arm circumference decreased between 0.9 and 6.1 cm (average 2.75 cm). The number of episodes of lymphangitis per year decreased from 1.8 to 0.2. CONCLUSION: Preoperative assessment is essential to select patients who can benefit from surgery for lymphedema and to choose the best surgical approach in each case. Our satisfactory results in well-selected cases encourage further research into surgical treatment for BCRL.

Autologous reconstruction of a complex form of Poland syndrome using 2 abdominal perforator free flaps.

Poland syndrome is the most frequent cause of congenital breast aplasia and hypoplasia. Breast and possible chest wall deformities can be treated with several surgical techniques, including implants, and pedicled or free flaps.We describe the case of a young patient with severe Poland syndrome with amastia, athelia, and deformity of the chest wall, and aplasia of 2 ribs. Marked hypoplasia of the ipsilateral latissimus dorsi muscle ruled out a reliable reconstructive option.Two perforator flaps were performed in a single-stage operation. A hemi-deep inferior epigastric perforator flap was harvested to correct the chest deformity, whereas the contralateral superficial inferior epigastric artery flap allowed breast reconstruction.No complications occurred and a subjectively and objectively pleasing cosmetic result was maintained at 3-year follow-up.

Paramuscular perforators in DIEAP flap for breast reconstruction.

UNLABELLED: One of the main steps in perforator flap surgery is to identify the dominant perforator. Using multidetector row computed tomography (MDCT) for the preoperative planning of deep inferior epigastric artery perforator (DIEAP) flap surgery, we identified a perforator with a large caliber, an excellent location in the middle abdominal region, and a totally extramuscular trajectory in a significant number of patients. We describe the frequency of this perforator and determine its characteristics. PATIENTS AND METHODS: We conducted a retrospective study of 482 patients who underwent 526 DIEAP flaps for breast reconstruction from October 2003 to October 2011. Mean age at surgery was 51.3 years old. A preoperative MDCT of abdominal vascularization was performed in all patients. RESULTS: MDCT identified a dominant perforator with a paramuscular course in 12.4% of abdominal walls. In all cases, it was located in the midline and emerged directly from the deep inferior epigastric system. Its mean caliber was 1.9 mm. The flap was harvested based on this perforator in all these patients, and mean harvest time was 51 minutes. The characteristics of this perforator made dissection easier and reduced morbidity at the donor site. There were no flap losses and the only complications were minor. CONCLUSION: We located a paramuscular perforator in 12.4% of patients undergoing breast reconstruction with abdominal perforator flaps. Its morphological features and extramuscular course make it the perforator of choice in DIEAP flap surgery.