Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: results over 24-months follow-up.

PURPOSE: Lymphedema is a debilitating condition that significantly affects patient's quality of life (QoL). The aim of this study was to assess the long-term outcomes after lymphaticovenous anastomosis (LVA) for extremity lymphedema. METHODS: A single-center prospective study on upper and lower extremity lymphedema patients was performed. All LVA procedures were preceded by outpatient Indocyanine Green (ICG) lymphography. Quality of life measured by the Lymph-ICF was the primary outcome. Limb circumference, use of compression garments, and frequency of cellulitis episodes and manual lymphatic drainage (MLD) sessions were secondary outcomes. RESULTS: One hundred consecutive patients, predominantly experiencing upper extremity lymphedema following breast cancer (n = 85), underwent a total of 132 LVAs. During a mean follow-up of 25 months, mean Lymph-ICF score significantly decreased from 43.9 preoperative to 30.6 postoperative, representing significant QoL improvement. Decrease in upper and lower limb circumference was observed in 52% of patients with a mean decrease of 6%. Overall mean circumference was not significantly different. Percentage of patients that could reduce compression garments in the upper and lower extremity group was 65% and 40%, respectively. Number of cellulitis episodes per year and MLD sessions per week showed a mean decrease of respectively 0.6 and 0.8 in the upper extremity and 0.4 and 1.0 in the lower extremity group. CONCLUSIONS: LVA resulted in significant QoL improvement in upper and lower extremity lymphedema patients. Limb circumference did not significantly improve but good results concerning compression garments, cellulitis episodes, and MLD sessions were obtained. Additionally, a simple and patient-friendly method for outpatient ICG lymphography is presented.

Intercostal nerve block of the anterior cutaneous branches and the sensibility of the female breast.

INTRODUCTION: Better sensation in the reconstructed breast improves the quality of life. Sensory nerve coaptation is a valuable addition to autologous breast reconstruction. There are few publications concerning the sensory nerves of the breast and the nipple-areola complex and reports are contradictory, so it is unknown which nerve is best suited as a recipient for coaptation. The current study serves as a proof of concept. MATERIALS AND METHODS: The areas innervated by the anterior cutaneous branches (ACBs) of the intercostal nerves (ICNs) were studied on two separate occasions in two healthy women. First, the ACBs of ICNs 2-5 were individually blocked using ultrasound. Next, the ACBs of all levels were blocked simultaneously. Sensation was measured using Semmes-Weinstein monofilaments. The numbed areas corresponding to the ICNs were drawn in a raster of 2 × 2 cm. RESULTS: The largest area was supplied by the ACB of the 4th ICN, located in the upper (UIQ) and the lower (LIQ) inner quadrants of the breast. The 2nd-largest area was supplied by the ACB of the 3rd ICN. Blockage of ACBs 2-5 affected sensation in the nipple and the areola. CONCLUSIONS: Blockage of all levels 2-5 partially affected sensation in the nipple-areola complex, suggesting innervation by a nerve plexus consisting of both ACBs and lateral cutaneous branches (LCBs). ACB4 supplied the largest area of the breast in the UIQ and LIQ and could be best suited for sensory nerve coaptation to optimize sensation in the autologously reconstructed breast.

Sensation of the autologous reconstructed breast improves quality of life: a pilot study.

PURPOSE: The number of breast cancer survivors continues to grow. Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. Impaired sensation remains a debilitating side effect with a significant impact on the quality of life. Microsurgical nerve coaptation of a sensory nerve has the potential to improve sensation of the reconstructed breast. This study investigates the effect of improved sensation of the reconstructed breast on the quality of life in breast cancer survivors. METHODS: A retrospective cohort study was performed in the Maastricht University Medical Center. Patients undergoing a DIEP flap breast reconstruction between January 2015 and January 2016 were included. The primary outcome was quality of life (BREAST-Q domain 'physical well-being of the chest'). The Semmes-Weinstein monofilaments were used for objective sensation measurement of the reconstructed breast(s). RESULTS: Eighteen patients with and 14 patients without nerve coaptation responded. Nipple reconstruction was the only characteristic that differed statistically significant between both groups (p = 0.04). The BREAST-Q score for the domain physical well-being of the chest was 77.89 ± 18.89 on average in patients with nerve coaptation and 66.21 ± 18.26 in patients without nerve coaptation (p = 0.09). Linear regression showed a statistically significant relation between objectively measured sensation and BREAST-Q score for the domain physical well-being of the chest with a regression coefficient of - 13.17 ± 3.61 (p < 0.01). CONCLUSIONS: Improved sensation in the autologous reconstructed breast, with the addition of microsurgical nerve coaptation, has a statistical significant positive impact on the quality of life in breast cancer survivors according to the BREAST-Q.

What does a breast feel like? A qualitative study among healthy women.

BACKGROUND: Restoring the body as normal as possible increases quality of life. Aesthetically, almost perfect breast reconstructions can be created. However, these reconstructed breasts have almost no sensation. Our hypothesis is that if we succeed in restoring sensation, this will increase quality of life. So far, little is written about the phenomenon of breast sensation, which makes it difficult to evaluate whether the quality of life increases after restored sensation. Therefore, the primary goal of this study is to determine what the importance and meaning is of breast sensation among healthy women. METHODS: A qualitative, descriptive phenomenological study was performed in an academic hospital between October 2016 and March 2017. A total of 10 semi-structured in-depth interviews were conducted in healthy women who did not undergo prior breast surgery. The sample size was based upon 'saturation'. The interviews were tape-recorded, transcribed verbatim, coded and analysed according to phenomenology keeping in mind the research question 'what is the importance and meaning of sensation of the breast?' RESULTS: Seven interrelated themes on how sensation of the breast is experienced were found: the absent breast (1), the present breast (2), the well-functioning breast (2a), the feminine breast (2b), the sensual breast (2c), the alien breast (2d), the safe breast (2d). CONCLUSIONS: The seven interrelated themes can form the basis to develop a quantitative research tool to evaluate quality of life after innervated breast reconstruction and can be implemented in counselling before breast reconstructive surgery in the form of shared treatment decisions.

Lymphatico-venous anastomosis as treatment for breast cancer-related lymphedema: a prospective study on quality of life.

PURPOSE: Lymphedema is a chronic and disabling sequel of breast cancer treatment that can be treated by lymphatico-venous anastomosis (LVA). Artificial connections between the venous and lymphatic system are performed supermicrosurgically. This prospective study analyses the effect of LVA on quality of life. METHODS: A prospective study was performed between November 2015 and July 2016 on consecutive patients in the Maastricht University Medical Centre. Quality of life was considered as the primary outcome, and the Lymphedema International Classification of Functioning (Lymph-ICF) questionnaire was used. Discontinuation of compressive stockings and arm volume, using the Upper Extremity Lymphedema index (UEL-index), were the secondary outcomes. RESULTS: Twenty women with early-stage breast cancer-related lymphedema (BCRL) were included. The mean age was 55.9 ± 4 years and the median BMI was 25.1 [21-30] kg/m2. The mean follow-up was 7.8 ± 1.5 months. Statistically significant improvement in quality of life was achieved in the total score and for all the quality of life domains after one year of follow-up (p < 0.05). The discontinuation rate in compressive stockings use was 85%. The difference in mean relative volume did not show a statistically significant decrease. CONCLUSIONS: LVA for early-stage BCRL resulted in a significant improvement in quality of life and a high rate in stocking discontinuation.

Outcomes of vascularized versus non-vascularized lymph node transplant in animal models for lymphedema. Review of the literature.

Lymph node transfer has been performed to treat lymphedema for several years. The goal of this procedure is to provide a bridge between the lymphatic system distal and proximal to the lymph node dissection. There is a lack of consensus about the necessity of an additional vascular anastomosis for the transplanted lymph nodes. A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE of animal studies using lymph node transplantation with and without additional vascularization was performed in March 2016. The strategy used for the search was: (("Models, Animal"[Mesh]) AND (("Lymphedema"[Mesh]) OR "Lymph Nodes"[Mesh]) OR "Lymph Node Excision"[Mesh])) AND ((vascularized lymph node transfer) OR ((non-vascularized lymph node transfer) OR lymph node graft)). The primary outcomes were: survival of transplanted lymph node and lymphatic vessel regeneration. Sixteen studies were included. Vascularization and the use of growth factors were significantly associated with lymph node survival. Lymphatic vessels regeneration was independent from vascularization. According to the results of the current study, additional vascular anastomosis might improve the transplanted lymph node survival. Further studies in both experimental and clinical setting are needed in order to support it. J. Surg. Oncol. 2017;115:32-36. © 2016 Wiley Periodicals, Inc.

Innervated full thickness grafts in distal finger amputations.

Innervated full thickness graft will be presented as an option to reconstruct a fingertip defect which might result in better sensibility than standard reconstruction using a full thickness graft without innervation. Also, anastomosing the nerve stumps can decrease the chance of developing neuroma.

Salvage of a DIEP Flap after Injury to the Inferior Epigastric Vessels after Laparoscopic Surgery.

The problem of previous laparoscopic scars specifically endangering the DIEP flap harvest for breast reconstruction has not been described yet. Even though in our center, preoperative imaging by means of an magnetic resonance angiography (MRA) is routinely performed before a bilateral DIEP-flap reconstruction, it may not correspond with the intraoperative findings. This case was presented to increase awareness among plastic surgeons about the complications after laparoscopic surgery and to emphasize the importance of thorough history taking when performing a DIEP flap breast reconstruction after previous laparoscopic procedures.

Breast Cancer-Related Lymphedema and Genetic Predisposition: A Systematic Review of the Literature.

Background: Secondary lymphedema is a complication following breast cancer therapy and constitutes the main form of lymphedema in the western world. The purpose of the current study was to provide a clear overview of the genetic predisposition and secondary lymphedema. Methods and Results: A systematic search was performed between February and June 2017 in MEDLINE and Embase. Search terms included Genes, Genetic Predisposition to Disease, Lymphedema, Breast Cancer Lymphedema, Secondary Lymphedema, Breast Cancer-Related Lymphedema, and Humans. Only original articles regarding the possible relationship between genetic variation and the development of secondary lymphedema in humans were included in this review. A total of 459 records were collected. After removal of duplicates, non-topic-related publications, and records not presenting original data, six full-text studies were included. Associations between genetic factors and the development of secondary lymphedema were found for variations in HGF, MET, GJC2, IL1A, IL4, IL6, IL10, IL13, VEGF-C, NFKB2, LCP-2, NRP-2, SYK, VCAM1, FOXC2, VEGFR2, VEGFR3, and RORC. Conclusions: In patients with secondary lymphedema following breast cancer therapy, genetic variations were found in 18 genes. These compelling, although preliminary, findings may suggest a possible role for genetic predisposition in the development of lymphedema following breast cancer therapy. This notion may add to the classical, more mechanistic explanation of secondary lymphedema.

Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction.

BACKGROUND: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction. METHODS: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin. RESULTS: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, -1.2; p < 0.001), which indicated that sensory recovery of the breast was significantly better in innervated compared with noninnervated DIEP flaps. For every month of follow-up, the mean monofilament value decreased by 0.083 in innervated flaps (p < 0.001) and 0.012 in noninnervated flaps (p < 0.001). Nerve coaptation significantly improved sensation in both immediate and delayed reconstructions. CONCLUSIONS: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction is associated with a significantly better sensory recovery in all areas of the reconstructed breast compared with noninnervated flaps. The length of follow-up was significantly associated with the sensory recovery.

Improvement of Symptoms after Lymphaticovenous Anastomosis in Patients with Abdominal Wall Lymphedema.

At our institution, we performed a lymphaticovenous anastomosis in patients with primary or secondary abdominal lymphedema. Patients report good outcomes and feel relieved of their complaints. To obtain good results, it is important to have decent knowledge on the anatomical state of the lymphatic system. In general, the lymphatic system of the lower abdomen can be compared with the system of the upper legs. According to our current case results, the abdominal area might be susceptible to lymphaticovenous anastomosis procedure. Further research should be performed to confirm the effect of the intervention and the imaging techniques to monitor the improvements.

Quality of Life Questionnaires in Breast Cancer-Related Lymphedema Patients: Review of the Literature.

PURPOSE: Lymphedema of the arm is one of the most common and underestimated side effects of breast cancer treatment. It is known to negatively affect the quality of life (QoL) in breast cancer survivors. However, there are multiple questionnaires used to measure QoL in lymphedema patients. The current study aimed to determine the most complete and accurate questionnaire. METHODS: A systematic literature search in Cochrane Library database CENTRAL, MEDLINE, and EMBASE was conducted in August 2016 by two independent researchers. The strategy used for the search was: (("Lymphedema"[Mesh]) AND ("Quality of life"[Mesh])). All QoL questionnaires for patients with breast cancer-related lymphedema (BCRL) were included. An overview of the assessed QoL domains and arm symptom-specific questions was made, to assess the most complete and accurate questionnaire. RESULTS: A total of 142 studies were identified, of which 49 met the inclusion criteria and 15 different questionnaires were extracted. The Lymphedema Quality of Life Inventory (LyQLI), assesses all QoL domains, except for the possibility of wearing the clothes of choice, and assess all specific arm symptoms. The Lymphedema Functioning, Disability, and Health (Lymph-ICF) Questionnaire assesses all QoL domains, except for sexual functioning, and does assess all specific arm symptoms. CONCLUSION: According to the results obtained, the LyQLI and Lymph-ICF questionnaires were the two most complete and accurate questionnaires to assess QoL in patients with BCRL, because these questionnaires assess the largest number of QoL domains and specific arm symptoms.

Effect of Lymphaticovenous Anastomosis in Breast Cancer-Related Lymphedema: A Review of the Literature.

BACKGROUND: Lymphedema affects ∼15% of all patients after breast cancer treatment. The aim of this review was to assess the clinical effects (improvement in arm circumference and quality of life) of lymphaticovenous anastomosis (LVA) in treating breast cancer-related lymphedema (BCRL). METHODS AND RESULTS: A systematic literature search was conducted in Medline, Embase and the Cochrane Library in July 2017, to identify all studies on LVA for the treatment of BCRL. The primary outcome was limb volume or circumference reduction and the secondary outcome was the improvement of quality of life. The search yielded 686 results, of which 15 articles were included in this review. All studies reported on BCRL in terms of volume or circumference reduction. Thirteen out of the included studies reported a positive surgical effect on reduction in volume or circumference. Twelve articles mentioned qualitative measures, being symptom improvement and improvement in quality of life. The number of patients who experienced symptoms relief ranged from 50% to 100% in the studies. CONCLUSIONS: The current review showed that the effects of LVA for the treatment of BCRL are variable among studies, although overall LVA seems effective in early stage BCRL. Higher quality studies are needed to confirm the effectiveness of LVA.

Comparing the sensation of common donor site regions for autologous breast reconstruction to that of a healthy breast.

INTRODUCTION: Autologous breast reconstruction has become the standard care for breast cancer patients. Although excellent cosmetic results can be achieved, most reconstructed breasts fail to regain normal sensation. Nerve coaptation of the flap has been suggested to improve sensation; the effect of the donor flap native sensory threshold on the degree of sensory restoration is yet to be determined. The aim of this study is to evaluate the differences in sensation between various potential donor site regions in comparison to the sensation of the healthy breast. PATIENTS AND METHODS: A cross-sectional study in healthy women was performed in the Maastricht University Medical Centre. Monofilaments were used to measure sensation in the breast and at different flap donor sites: deep inferior epigastric perforator (DIEP), lateral thigh perforator (LTP), profunda artery perforator (PAP), superior gluteal artery perforator (SGAP) and transverse musculocutaneous gracilis (TMG) flaps. The Wilcoxon signed rank test was used to analyse statistical significance in sensation. RESULTS: Fifty women with a mean age of 49 ± 2.72 years and mean BMI of 26.14 ± 0.89 kg/m2 were included in the study. The median monofilament value of the normal breasts was 2.97(2.56-3.55). The median monofilament value of each donor site and p value when compared to the healthy breast were as follows: DIEP flap, 2.62 (2.36-3.22) p < 0.01; LTP flap, 3.61 (2.83-4.08) p <0.01; PAP flap, 3.09 (2.67-3.5) p = 0.97; SGAP flap, 3.22 (2.64-3.87) p = 0.01; and TMG flap, 3.03 (2.6-3.47) p = 0.69. CONCLUSIONS: There is a significant difference in sensation between the various donor site regions for breast reconstruction and the healthy breast. This may be taken into consideration for donor site selection.

Near-infrared fluorescence image-guidance in plastic surgery: A systematic review.

BACKGROUND: Near-infrared fluorescence (NIRF) imaging technique, after administration of contrast agents with fluorescent characteristics in the near-infrared (700-900 nm) range, is considered to possess great potential for the future of plastic surgery, given its capacity for perioperative, real-time anatomical guidance and identification. This study aimed to provide a comprehensive literature review concerning current and potential future applications of NIRF imaging in plastic surgery, thereby guiding future research. METHODS: A systematic literature search was performed in databases of Cochrane Library CENTRAL, MEDLINE, and EMBASE (last search Oct 2017) regarding NIRF imaging in plastic surgery. Identified articles were screened and checked for eligibility by two authors independently. RESULTS: Forty-eight selected studies included 1166 animal/human subjects in total. NIRF imaging was described for a variety of (pre)clinical applications in plastic surgery. Thirty-two articles used NIRF angiography, i.e., vascular imaging after intravenous dye administration. Ten articles reported on NIRF lymphography after subcutaneous dye administration. Although currently most applied, general protocols for dosage and timing of dye administration for NIRF angiography and lymphography are still lacking. Three articles applied NIRF to detect nerve injury, and another three studies described other novel applications in plastic surgery. CONCLUSIONS: Future standard implementation of novel intraoperative optical techniques, such as NIRF imaging, could significantly contribute to perioperative anatomy guidance and facilitate critical decision-making in plastic surgical procedures. Further investigation (i.e., large multicenter randomized controlled trials) is mandatory to establish the true value of this innovative surgical imaging technique in standard clinical practice and to aid in forming consensus on protocols for general use.Level of Evidence: Not ratable.