Larger recipient vein caliber during lymphatic microsurgical preventive healing approach (LYMPHA) is associated with lower lymphedema rates.

BACKGROUND: The lymphatic microsurgical preventive healing approach reduces the risk of lymphedema after axillary lymph node dissection. We identified surgical factors of Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) that influence lymphedema rates focusing on the vein caliber used. METHODS: A single-institution retrospective cohort study included breast cancer patients undergoing axillary lymph node dissection and LYMPHA (April 2021-November 2022) with a follow-up of at least 1 year. Lymphedema was defined as an increase of ≥10 units in the lymphedema index (measured using bioimpedance spectroscopy) from baseline. The primary outcome was the correlation between the lymphedema index of patients with a vein caliber of ≤2 mm vs > 2 mm. RESULTS: Forty-eight patients with documented vein caliber were analyzed. The median baseline lymphedema index in patients with a vein caliber ≤2 mm was 2 (SD 3.04) and 2.2 (SD 2.03) for vein caliber >2 mm. (P = .57). After 1-year follow-up, the L-dex was 6.20 (SD 7.48) for vein caliber ≤2 mm and 1.60 (SD 5.85) for vein caliber >2 mm (P = .02). The L-dex difference from baseline was higher for vein caliber ≤2 mm compared to >2 mm (2.9 vs 0.10, P = .02). Larger vein caliber was associated with a lower L-dex at 3 months (P = .04) and a lesser difference from the baseline after 1 year (P = .03). This was maintained on univariate analysis and multivariate analysis controlling for radiation, chemotherapy, and number of lymph nodes excised. CONCLUSION: Vein caliber >2 mm during LYMPHA axillary lymph node dissection is associated with a lower postoperative lymphedema index. These results can be enhanced by a multi-institutional study to improve standardization of this technique.

Scar Decompression in Managing Breast Cancer-Related Lymphedema: Is it Needed?

BACKGROUND: Mastectomy, axillary lymph node dissection, and irradiation for breast cancer commonly result in perivascular and axillary scarring. This scarring is thought to cause functional venous stenosis that leads to downstream venous hypertension in the affected extremity. Standard surgical practice is to decompress perivascular scarring at the time of physiologic lymphedema surgery in patients with breast cancer-related lymphedema (BCRL). However, it is unknown whether this scar release influences surgical outcomes. The purpose of this study was to evaluate the prevalence of functional venous stenosis in patients with BCRL and determine whether scar decompression is a necessary step in physiologic lymphedema surgery. METHODS: The authors conducted a retrospective review of 64 patients with unilateral BCRL that presented to our lymphedema center between January 2020 and October 2022. Radiologist reports of venous duplex ultrasound for the bilateral upper extremities identified any disturbances in venous flow or indications of venous stenosis. RESULTS: Of the 64 patients with BCRL, 78% (n = 50) had prior axillary lymph node dissection. Forty-seven (73%) patients completed ultrasound imaging, of which, one patient (2%) had venous stenosis in the affected lymphedematous extremity identified on duplex ultrasound that may have suggested functional scarring. Vascularized lymph node transfer (VLNT) without scar decompression was performed in six patients (9%). Average preoperative Lymphedema Life Impact Scale and Lymphedema Index scores were 35 and 19 units, with a mean decrease of 23 (67%) and 6 (30%) units postoperatively. CONCLUSION: Most patients with BCRL did not have identifiable functional venous stenosis on duplex ultrasound, apart from one patient with suspected postthrombotic changes. All six patients that received VLNT without scar decompression had a successful outcome with decreased measures of lymphedema postoperatively. Scar decompression may therefore be unnecessary in physiologic lymphedema surgery, reducing operative times and avoiding risk of injury to neurovascular structures of the axilla.

Initial Experience with Unidirectional Barbed Suture for Abdominal Donor Site Closure in Deep Inferior Epigastric Perforator Flap Breast Reconstruction.

Background: The deep inferior epigastric perforator (DIEP) flap is a predominant technique for autologous breast reconstruction. However, the best method of abdominal fascial closure in this technique is not well defined. This study details our initial experience with unidirectional barbed suture-only repair of abdominal donor site fascia. Methods: Patients who underwent DIEP flap breast reconstruction and abdominal fascial closure with Stratafix Symmetric Polydioxanone PDS Plus were retrospectively reviewed. Information regarding pertinent patient history, medical comorbidities, risk factors, and surgical technique was extracted, along with the incidence of eight separate postoperative abdominal surgical site occurrences. Results: Retrospective review identified 43 patients who underwent 19 unilateral and 24 bilateral DIEP flap breast reconstruction procedures (n = 67). Average patient follow-up was 791 days (range 153-1769). Six patients (14%) had a complication of the donor site. Seroma was most frequent (n = 3, 7%), followed by surgical site infection (n = 2, 5%). One patient had incisional dehiscence (2%) and another patient developed bulging (2%). No patients had chronic pain, weakness, hematoma, or hernia postoperatively. Patients with donor site complications had a history of abdominal/pelvic surgery significantly more often than the patients without donor site complications (100% versus 49%; P = 0.032). Conclusions: Abdominal fascial repair with Stratafix Symmetric suture alone led to low rates of abdominal donor site morbidity, including no hernia and rare bulging, following DIEP flap breast reconstruction. Additional advantages of this technique may be reduced operative times and lower operative costs compared with alternative methods of fascial repair, although prospective and randomized studies are warranted.

Prevalence, clinical characteristics, and management of silicone lymphadenopathy: A systematic review of the literature.

INTRODUCTION: Implant-based breast augmentations and reconstructions are one of the most common surgical procedures performed by plastic surgeons in the United States, which has rapidly increased in popularity since the 2000s. Silicone lymphadenopathy (SL) is a complication of breast implants that involves migration of silicone to nearby soft tissue/lymph nodes. Data on its clinical features and management is scarce. METHODS: SL-related search terms were used to find articles in 3 databases. Of 598 articles, 101 studies met the inclusion criteria. Demographics, clinical presentation, workup, and management data were analyzed. RESULTS: Of 279 cases of SL and 107 with information on initial diagnosis, 35 (33%) were incidental. The most common symptom was painless lymphadenopathy, followed by painful lymphadenopathy. 251 (95%) and 13 (5%) patients had silicone and saline implants, respectively. 149 (68%) patients had implant rupture. Axillary lymphadenopathy was the most affected region (136 cases, 72%), followed by internal mammary (40 cases, 21%), cervical/supraclavicular (36 cases, 19%), and mediastinal (24 cases, 13%) regions. 25% of patients underwent fine-needle aspiration, 12% core needle biopsy, and 59% excisional biopsy. 32% of cases underwent explantation and/or implant exchange. The most common indication for surgery was implant rupture. Histology showed multinucleated giant cells, large histiocytes, and silicone accumulation. CONCLUSIONS: SL is a complication associated with breast implants. The majority of patients are asymptomatic, and most cases are managed conservatively. Minority need a biopsy and surgical interventions due to abnormal imaging, persistent symptoms, and/or implant rupture. Workup and management should be tailored to the patient.

Techniques and Outcomes in Microsurgical Treatment of Posttraumatic Lymphedema: A Systematic Review.

BACKGROUND: The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL. METHODS: A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded. RESULTS: A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements. CONCLUSION: PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies.

Lymphedema Surgical Education and Faculty Demographics in United States Plastic Surgery Residency Programs.

BACKGROUND: Recent advancements in supermicrosurgery and promising preliminary outcomes have led to a surge in physiologic lymphedema surgery. This study is the first to evaluate lymphedema surgical education among U.S. plastic surgery residency programs, along with the background and experience of plastic surgeons subspecializing in the field. METHODS: Cross-sectional evaluation of 103 accredited U.S. plastic surgery residency programs was performed in January 2023. Web-based searches of program curricula, faculty profiles, and main institutional pages indicated whether a program provided nonclinical or clinical exposure to lymphedema surgery. Review of online faculty profiles, surname searches, Doximity, and Scopus determined the perceived demographics, academic productivity, and procedures performed by lymphedema surgeons. RESULTS: Compared with the 11 programs that incorporated lymphedema surgery into their online curriculum, 67 programs had a rotation site with a surgeon performing lymphedema procedures. Of the 33 programs without evidence of clinical exposure, 76% (n = 25) did not provide or specify providing elective time. Faculty perceived to be female or a race underrepresented in plastic surgery had significantly more assistant professor titles (p < 0.0214) and significantly fewer years of experience (p < 0.0293) than their counterparts. CONCLUSION: Great variation in lymphedema surgical education exists among U.S. plastic surgery residency programs. While few programs incorporate lymphedema surgery into their advertised curriculum, programs without clinical exposure frequently did not provide elective time to obtain it. Faculty that were female or a race underrepresented in plastic surgery were most often early in their career, suggesting lymphedema surgeons may grow increasingly diverse in years to come.

The utility of computed tomography venography in the routine evaluation of patients who present to a lymphedema center with lower extremity edema.

OBJECTIVE: Computed tomography venography (CTV) is not routinely used to screen patients presenting with a presumed lower extremity lymphedema diagnosis for left iliac vein obstruction (IVO) or May-Thurner syndrome (MTS). The objective of this study is to determine the utility of routine CTV screening for these patients by evaluating the proportion presenting with clinically significant CTV-identified left IVO. METHODS: We retrospectively reviewed 121 patients who had presented to our lymphedema center with lower extremity edema between November 2020 and May 2022. Information regarding demographics, comorbidities, lymphedema characteristics, and imaging reports was collected. Cases of IVO present on CTV were reviewed by a multidisciplinary team to determine the clinical significance of the CTV findings. RESULTS: Of the patients with complete imaging studies, 49% (n = 25) had abnormal lymphoscintigraphy findings, 45% (n = 46) had reflux on ultrasound, and 11.4% (n = 9) had IVO on CTV. Seven patients (6%) had CTV findings of IVO and edema of either the isolated left (n = 4) or bilateral (n = 3) lower extremities. Cases of IVO on CTV were determined by the multidisciplinary team to be the predominant cause of lower extremity edema for three of these seven cases (43%; or 2.5% of all 121 patients). CONCLUSIONS: Six percent of patients presenting to a lymphedema center with lower extremity edema had left-sided IVO on CTV suggestive of MTS. However, the cases of IVO were determined to be clinically significant <50% of the time or for 2.5% of all patients. CTV should be reserved for patients with isolated left-sided or bilateral lower extremity edema with a greater left-sided component and a history of findings that raise clinical suspicion for MTS.