A Retrospective Self-Controlled Study Evaluating the Prophylactic Effects of CACIPLIQ20 on Postsurgical Scars.

Background: CACIPLIQ20 (OTR3, Paris, France) is a medical device used for the treatment of chronic skin ulcers. It contains a heparan sulfate mimetic that accelerates tissue healing by stabilizing matrix proteins and protecting heparin-binding growth factors. In humans, an open self-controlled study suggested that the topical application of CACIPLIQ20 optimizes skin healing following surgery. Objectives: To expand previous findings using a different CACIPLIQ20 administration regimen. Methods: Twenty-four females were referred for breast-reduction surgery. Each patient had their own control with 1 CACIPLIQ20-treated and 1 saline-treated control breast. The treated side (right or left) was randomly assigned by the operating surgeon. Scar appearance was assessed by 6 independent raters using a global visual scar comparison scale based on scar photographs. All raters were blinded toward the CACIPLIQ20-treated side. Results: The follow-up period following surgery ranged from 1 to 12 months with a median follow-up of 6 months. Overall, there was a mean improvement of 15.2% (SD = 26.7) in favor of CACIPLIQ20 (P = .016). On the CACIPLIQ20-treated side, the mean score per patient was above 20% in 11 patients and above 30% improvement in 8 cases. In contrast, only 3 patients were considered improved by at least 20% on the control side and only 1 above 30%. A comparison of different application regimens suggested that the best trend was obtained with a single administration of CACIPLIQ20 at Day 0. Conclusions: In conclusion, CACIPLIQ20 could represent an interesting scar prophylactic therapy, based on a single administration at the time of surgery, and without any known adverse effects.

Use of fluorescence imaging during lymphatic surgery: A Delphi survey of experts worldwide.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly used during lymphedema patient management. However, to date, no guidelines exist on when it should and should not be used or how it should be performed. Our objective was to have an international panel of experts identify areas of consensus and nonconsensus in current attitudes and practices in fluorescence imaging with indocyanine green use during lymphedema surgery patient management. METHODS: A 2-round Delphi study was conducted involving 18 experts in the use of fluorescence imaging during lymphatic surgery, all asked to vote on 49 statements on patient preparation and contraindications (n = 7 statements), indocyanine green dosing and administration (n = 10), fluorescence imaging uses and potential advantages (n = 16), and potential disadvantages and training needs (n = 16). RESULTS: Consensus ultimately was reached on 40/49 statements, including consistent consensus regarding the value of fluorescence imaging with indocyanine green in almost all facets of lymphedema patient management, including early detection, assessing disease extent, preoperative work-up, surgical planning, intraoperative guidance, monitoring short- and longer-term outcomes, quality control, and resident training. All experts felt it was very safe, while 94% felt it should be part of routine care and that indocyanine green was superior to colored dyes and ultrasound. Nonetheless, there also was consensus that limited high-quality evidence remains a barrier to its widespread use and that patients should still be provided with specific information and asked to sign specific consent for both fluorescence imaging and indocyanine green. CONCLUSION: Fluorescence imaging with or without indocyanine green appears to have several roles in lymphedema prevention, diagnosis, assessment, and treatment.

Primary lymphoedema.

Lymphoedema is the swelling of one or several parts of the body owing to lymph accumulation in the extracellular space. It is often chronic, worsens if untreated, predisposes to infections and causes an important reduction in quality of life. Primary lymphoedema (PLE) is thought to result from abnormal development and/or functioning of the lymphatic system, can present in isolation or as part of a syndrome, and can be present at birth or develop later in life. Mutations in numerous genes involved in the initial formation of lymphatic vessels (including valves) as well as in the growth and expansion of the lymphatic system and associated pathways have been identified in syndromic and non-syndromic forms of PLE. Thus, the current hypothesis is that most cases of PLE have a genetic origin, although a causative mutation is identified in only about one-third of affected individuals. Diagnosis relies on clinical presentation, imaging of the structure and functionality of the lymphatics, and in genetic analyses. Management aims at reducing or preventing swelling by compression therapy (with manual drainage, exercise and compressive garments) and, in carefully selected cases, by various surgical techniques. Individuals with PLE often have a reduced quality of life owing to the psychosocial and lifelong management burden associated with their chronic condition. Improved understanding of the underlying genetic origins of PLE will translate into more accurate diagnosis and prognosis and personalized treatment.

Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer.

Post-traumatic localized hand lymphedema is a rare situation and its diagnosis may be difficult, causing lack of care leading to failure of care. Our case study is of two young women with massive post-traumatic hand lymphedema who were treated for algodystrophy for 2 years, and whose bandages and physiotherapy were unsuccessful. Major social and psychological consequences due to difficulty with diagnosis and management resulting in inappropriate tests and therapeutic treatment were prescribed due to these issues. Noncontrast magnetic resonance lymphography revealed complete lymphatic vessel blockage in the hand and wrist. A vascularized lymph node flap harvested at the groin level was transferred to the elbow level 1 month after local dermolipectomy. These procedures resulted in the restoration of lymphatic flow. Both patients were definitely cured, and they returned to normal life within 6 months after surgery. Lymph node flap transfer associated with dermolipectomy may cure massive localized lymphedema in selected cases.

Noncontrast Magnetic Resonance Lymphography for Evaluation of Lymph Node Transfer for Secondary Upper Limb Lymphedema.

BACKGROUND: The authors' purpose was to evaluate the results of axillary lymph node transplantation with noncontrast magnetic resonance lymphography in 15 patients with secondary upper limb lymphedema. METHODS: Fifteen female patients with lymphedema following breast cancer treatment underwent lymph node transplantation. Noncontrast magnetic resonance lymphography was obtained with a free-breathing three-dimensional fast spin-echo sequence. Image analysis included criteria both before surgery (i.e., severity of lymphedema graded as absent, mild, moderate, or severe; involvement of the muscular compartment; and distal dilated lymphatic vessels) and after surgery (i.e., visualization of the site of transplantation; visualization of transplanted lymph nodes; and severity of lymphedema with regard to pretransplantation severity, namely, improvement, stability, or aggravation). Clinically, circumferential measures were performed at four different levels. RESULTS: Follow-up magnetic resonance examinations were performed at least 6 months after lymph node transplantation, with a longest follow-up time of 42 months. In two patients, no lymphedema was visualized before lymph node transplantation with magnetic resonance lymphography. In the other 13 patients, lymphedema was mild in four patients, moderate in five patients, and severe in the other four patients. After lymph node transplantation, an improvement of upper limb lymphedema was observed in seven of nine patients with moderate or severe upper limb lymphedema. In the 11 patients in whom comparison of magnetic resonance lymphography with circumferential measurement was available, evaluations were concordant in 10 cases. CONCLUSION: Noncontrast magnetic resonance lymphography may be used as an objective technique to analyze the results of lymph node transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lymph node flap transfer for patients with secondary lower limb lymphedema.

BACKGROUND: Previous authors have shown benefits from the use of lymph node flap transfer (LNFT) to treat lymphedema of the arms, but there is little evidence for its use for lower limb lymphedema. We performed a retrospective analysis of a series of patients suffering from secondary lower limb lymphedema treated with a free LNFT. METHODS: 52 cases of LNFT to treat 41 legs in 38 patients with secondary lymphedema were retrospectively reviewed. The causes of the lymphedema included lymphedema secondary to hysterectomy for uterine cancer, melanoma resections on the leg, lymphoma treatment and testicular cancer, cosmetic surgery to the limb, lipoma resection at the inguinal region, and a saphenectomy. Patients had been suffering with lymphedema for an average of 9.1 ± 7.3 years at the time of LNFT. RESULTS: Eleven patients (28.9%) presented with minor complications treated conservatively. For 23 legs there was enough data to follow limb volume evolution after a single LNFT. Total volume reduction in eight legs (two patients with no measures of the healthy limb and three bilateral) was 7.1 ± 8.6%. Another group of 15 patients with unilateral lymphedema had an average 46.3 ± 34.7% reduction of excess volume. Better results (>30% REV) were associated with smaller preoperative excess volume (P = 0.045). CONCLUSION: Patients with secondary leg lymphedema can benefit from LNFT. Results in patients with mild presentations seem to be better than in more severe cases. © 2014 Wiley Periodicals, Inc. Microsurgery 37:29-33, 2017.

Noncontrast Magnetic Resonance Lymphography.

BACKGROUND: Different imaging techniques have been used for the investigation of the lymphatic channels and lymph glands. Noncontrast magnetic resonance (MR) lymphography has significant advantages in comparison with other imaging modalities. METHODS: Noncontrast MR lymphography uses very heavily T2-weighted fast spin echo sequences which obtain a nearly complete signal loss in tissue background and specific display of lymphatic vessels with a long T2 relaxation time. The raw data can be processed with different algorithms such as maximum intensity projection algorithm to obtain an anatomic representation. RESULTS: Standard T2-weighted MR images easily demonstrate the location of edema. It appears as subcutaneous infiltration of soft tissue with a classical honeycomb pattern. True collection around the muscular area may be demonstrated in case of severe lymphedema. Lymph nodes may be normal in size, number, and signal intensity; in other cases, lymph nodes may be smaller in size or number of lymph nodes may be restricted. MR lymphography allows a classification of lymphedema in aplasia (no collecting vessels demonstrated); hypoplasia (a small number of lymphatic vessels), and numerical hyperplasia or hyperplasia (with an increased number of lymphatic vessels of greater and abnormal diameter). CONCLUSION: Noncontrast MR lymphography is a unique noninvasive imaging modality for the diagnosis of lymphedema. It can be used for positive diagnosis, differential diagnosis, and specific evaluation of lymphedema severity. It may also be used for follow-up evaluation after treatment.

Surgical treatment of congenital lymphedema.

Lymphedema is a pathologic condition that results from a disturbance of the lymphatic system, with localized fluid retention and tissue swelling. Primary lymphedema is a congenital disorder, caused by a malformation of lymph vessels or nodes. Major progress has been achieved in the radiologic diagnosis of patients affected by lymphedema. The ideal treatment of the affected limb should restore function and cosmetic appearance. Surgical treatment is an alternative method of controlling chronic lymphedema. Free lymph nodes autologous transplantation is a new approach for lymphatic reconstruction in hypoplastic forms of primary lymphedema. The transferred nodes pump extracellular liquid out of the affected limb and contain germinative cells that improve immune function.

Microlymphatic surgery for the treatment of iatrogenic lymphedema.

Lymphedema is a chronic and progressive condition that occurs after cancer treatment. Autologous lymph node transplant, or microsurgical vascularized lymph node transfer (ALNT), is a surgical treatment option that brings vascularized vascular endothelial growth factor-C-producing tissue into the operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Operative techniques for upper- and lower-extremity ALNT are described with 3 donor lymph node flaps (inguinal, thoracic, cervical). Surgical technique is described for the combination of ALNT with abdominal flaps and nonabdominal flaps. Imaging showing restoration of lymphatic drainage after ALNT is shown.

Postmastectomy neuropathic pain: results of microsurgical lymph nodes transplantation.

UNLABELLED: Postmastectomy chronic pain may be divided into widespread and regional pain. Almost half patients with regional pain, which is more likely related to neuropathic phenomena, do not benefit any pain relief from medication. Our purpose was to report results on pain relief obtained by axillary lymph nodes autotransplantation. METHODS: Six patients presented with chronic regional neuropathic pains and upper limb lymphedema after breast cancer surgery and radiation therapy. Despite medication, pain was intolerable and daily activity dramatically reduced. Lymph nodes were harvested in the femoral region, transferred to the axillary region and transplanted by microsurgical procedures. RESULTS: Lymphedema resolved in 5 out of 6 patients. Pain was relieved in all, permitting return to work and daily activity; analgesic medication was discontinued. CONCLUSION: This procedure proved efficient and may be advocated in case of neuropathic pain when discussing lymphedema management.

Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation.

BACKGROUND AND OBJECTIVES: Lymphedema complicating breast cancer treatment remains a challenging problem. The purpose of this study was to analyze the long-term results following microsurgical lymph node (LN) transplantation. METHODS: Twenty-four female patients with lymphedema for more than 5 years underwent LN transplantation. They were treated by physiotherapy and resistant to it. LNs were harvested in the femoral region, transferred to the axillary region, and transplanted by microsurgical procedures. Long-term results were evaluated according to skin elasticity, decrease, or disappearance of lymphedema assessed by measurements, isotopic lymphangiography, and ability to stop physiotherapy. RESULTS: The postoperative period was uneventful; skin infectious diseases disappeared in all patients. Upper limb perimeter returned to normal in 10 cases, decreased in 12 cases, and remained unchanged in 2 cases. Five of 16 (31%) isotopic lymphoscintigraphies demonstrated activity of the transplanted nodes. Physiotherapy was discontinued in 15 patients (62.5%). Ten patients were considered as cured, important improvement was noted in 12 patients, and only 2 patients were not improved. CONCLUSION: LN transplantation is a safe procedure permitting good long-term results, disappearance, or a noteworthy improvement, in postmastectomy lymphedema, especially in the early stages of the disease.