A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema.

BACKGROUND: Vascularized lymph node transfer (VLNT) has become an increasingly popular technique for treating lymphedema. However, although many studies have been performed, its efficacy in increasing patients' quality of life (QoL) and reducing lymphedema in the affected body part has remained controversial. In the present systematic review, we summarized the evidence for VLNT for treating breast cancer-related lymphedema. METHODS: The MEDLINE, Embase, and Cochrane Central databases were searched for studies of patients with breast cancer-related lymphedema who had received VLNT. The study methods were assessed using the MINORS (methodologic index for nonrandomized studies) tool. The primary outcomes were the change in volume difference between the arms and QoL. The secondary outcomes were skin infection, complications, and discontinuation of compression garment use. RESULTS: A total of 17 studies were included for qualitative synthesis and 8 for meta-analysis. The average reduction rate between the healthy and affected arms in the studies included in the meta-analysis was 40.31%. Five studies had evaluated QoL, and all five studies had reported that QoL was significantly increased. Eight studies had evaluated skin infections, of which three had reported the annual infection rates before and after surgery. In these studies, infection rate had decreased significantly. Three studies had described usage of compression garments. When the patients were pooled, 27 of 60 were able to discontinue use of the compression garment. The donor and recipient complication rates were 12.1% and 7.3%, respectively. CONCLUSIONS: The current evidence indicates that VLNT can improve the volume differences between the arms in patients with unilateral lymphedema by ∼40%. In addition, although determined from a few studies, it is likely that VLNT has a positive effect on patients' QoL, the number of skin infections, and compression garment usage and coincided with a low complication rate.

Breast reconstruction with the extended profunda artery perforator flap.

BACKGROUND: The profunda artery perforator (PAP) flap is a reliable flap for breast reconstruction. By extending the traditional flap, it is possible to include more tissue and thereby enhance flap volume. The aim of this study is to demonstrate the technique for extended profundal artery perforator flap harvest and to demonstrate results in a population otherwise not suited for autologous breast reconstruction. METHODS: Retrospective chart review of all patients who received extended PAP flap breast reconstruction between 2016 and 2018 was performed. Patient demographics, perioperative data, and postoperative complications were recorded in a pre-defined form and analyzed. A fully illustrated and step-by-step description of the procedure was created and included. RESULTS: A total of 46 extended PAP flaps for breast reconstruction were performed on 28 patients. Forty-three were 'regular' extended PAP flaps, one was a stacked flap, and two were transverse myocutaneous gracilis flaps with extended PAP flap skin design. Mean pre-operative breast volume was 330 cc, and mean flap weight was 400 g. The success rate was high (97.8%), and complications included one partial flap loss (2.2%), one wound dehiscence of the breast (2.2%), and wound dehiscence of the donor site (11 patients, 23.9%). CONCLUSIONS: The modified and extended profunda artery perforator flap is an excellent autologous tissue option for breast reconstruction even in large-breasted patients or patients with a relatively low body mass index. Advantages include higher flap volume, reliable blood supply, higher skin volume, and the possibility of choosing from several perforators, making dissection more convenient.

Pseudoangiomatous stromal hyperplasia: an unsuspected cause of anisomasty.

Breast asymmetry can be congenital or developmental, however a tumorous growth may be the cause of this condition after puberty. A 19-year-old female presented with a slowly developing breast asymmetry pre-operatively diagnosed as Pseudoangiomatous Stromal Hyperplasia (PASH). The patient underwent tumour excision with breast gland remodelling. Postoperative course was uneventful.

Submental flap for vascularized lymph node transfer; a CTA-based study on lymph node distribution.

BACKGROUND: Amongst various options of vascularized lymph node transfers, the submental flap has the lowest risk for iatrogenic lymphedema. The aim of this study was to gain insight into distribution, number, and size of lymph nodes along the mandible using computed tomography angiography (CTA). METHODS: A total of 52 CTA scans of head/neck region were evaluated retrospectively. Lymph nodes in the submental and submandibular region, related to the origin of the submental artery, were recorded using a three-dimensional coordinate system, and standardized using an iterative closest point algorithm. Results were analyzed for gender, location, size, and number. RESULTS: The mean number and size of lymph nodes were 5.30 ± 2.00 and 5.28 ± 1.29 mm, respectively. The mean distance of the lymph nodes to the origin of the submental artery was 25.53 ± 15.27 mm. There was no significant difference between both sides when comparing size (left: 5.39 ± 1.28; right: 5.17 ± 1.34; P = .19), number (left: 5.46 ± 2.10; right: 5.17 ± 1.96; P = .49), and distance (left: 24.78 ± 12.23; right: 26.32 ± 14.73; P = .19). No significance was found between males and females concerning number (P = .60), size (P = .50), and distance (P = .06). CONCLUSION: The variance of lymph node distribution along the mandible may warrant conducting a CTA scan to maximize the number of transferred lymph nodes and aid in flap design.

Alternative Perforator Options for Insufficient Profunda Artery Perforators: A Case and Anatomical Study.

INTRODUCTION: The profunda artery perforator (PAP) flap can be an alternative to the deep inferior epigastric artery flap. However, in some cases, the PAP may not be adequate to perfuse the whole flap. In this study, we describe 3 cases in which an alternative perforator was used for PAP flap perfusion. In addition, we describe an anatomical study to explore the perforasome of the PAP and alternative perforators. MATERIALS AND METHODS: Three cases are described in which an alternative perforator was used to successfully perfuse the pap flap. For the anatomical study, 7 PAP flaps were raised from cadavers. Ink was injected in the PAP, the gracilis perforator (GP) and the descending branch of the inferior gluteal artery perforator (DBIGA). Then, perfused area of the flap by each perforator was calculated. RESULTS: The 3 patients with alternative perforators recovered without complications, in addition, no signs of fat necrosis were observed. Concerning the anatomical study, mean perfusion area of the PAP pedicle was 204 ± 90 cm (range, 141-364 cm). The GP and the DBIGA had a perfusion area of 182 ± 42 cm (range, 123-235 cm) and 157 ± 22 cm (range, 136-192), respectively. CONCLUSION: Although the PAP flap has considerable benefits over the more traditional inferior gluteal artery perforator and transverse upper gracilis flaps, a plastic surgeon might encounter a PAP flap perforator that is not deemed viable for flap perfusion. In these cases, the GP and DBIGA may be suitable "escape" alternatives to complete the reconstruction.

The inter-rater and test-retest reliability of skin thickness and skin elasticity measurements by the DermaLab Combo in healthy participants.

BACKGROUND: For several purposes, skin parameters like thickness and elasticity can be measured. However, little is known about the accuracy of those measurements. AIM: The aim of this study was to determine the intrarater and test-retest reliability of skin thickness and elasticity measurements performed with the DermaLab Combo®. METHODS: A total of 49 participants were included in this study. Skin thickness and elasticity were measured at six defined locations on the dominant arm. Measurements were repeated two times by the same observer to determine the test-retest reliability. To determine the inter-rater reliability, a second observer repeated the measurements once. RESULTS: Inter-rater and test-retest reliability for elasticity measurements fluctuates per location and per parameter: Inter-rater intraclass correlation coefficient (ICC) ranged from 0.23 to 0.80, and test-retest ICC ranged from 0.25 to 0.84. Skin thickness was measured reliable by every observer on every location, with a test-retest ICC ranging from 0.71 to 0.83 and an inter-rater ICC ranging from 0.69 to 0.80. CONCLUSION: The DermaLab Combo® showed a good inter-rater reliability when measuring skin thickness and elasticity. Not all locations are suitable for reliable inter-rater or test-retest measurements. The device is difficult to use by inexperienced users, as the echo probe is sensitive to small movements.

The Long-term Patency of Lymphaticovenular Anastomosis in Breast Cancer-Related Lymphedema.

BACKGROUND AND OBJECTIVES: Lymphedema is a condition that can greatly affect patient's quality of life. Promising results have been described with lymphaticovenular anastomosis (LVA) in the treatment of lymphedema. It is currently unknown at what rate anastomoses remain functional after a longer follow-up. The aim of this study was to determine LVA patency at 1-year follow-up. METHODS: Retrospective chart review was performed on patients who underwent LVA surgery. Patients who had indocyanine green lymphography performed at 12 months' follow-up after LVA were included in this study. Volume measurements were performed prior to surgery and at 6 and 12 months' follow-up. Patients quality of life was measured prior to surgery and at 6 months' follow-up. RESULTS: Twelve patients met inclusion criteria. In total, 15 (56.5%) of 23 LVAs were considered patent. In 8 patients (66.7%), at least 1 patent LVA was visible. The volume difference between the healthy and affected arms decreased 32.3% on average. Quality of life increased with 1.4 points on average. CONCLUSIONS: This study is, to our knowledge, the first to evaluate long-term patency of LVA in upper limb lymphedema. Our study demonstrates that at least 56.5% of the anastomoses created are patent after 1-year follow-up.

Current insights into extracorporeal perfusion of free tissue flaps and extremities: a systematic review and data synthesis.

BACKGROUND: Extracorporeal perfusion is a promising new technique for prolonged preservation of free flaps and extremities; however, uncertainties on perfusion settings and efficacy still exist. No overview of literature is currently available. This review systematically appraised available evidence comparing extracorporeal perfusion to static storage. MATERIALS AND METHODS: An electronic systematic search was performed on June 12, 2016, in MEDLINE and EMBASE. Articles were included when evaluating the effect of extracorporeal perfusion of free flaps or extremities compared to that of a control group. Two independent researchers conducted the selection process, critical appraisal, and data extraction. RESULTS: Of 3485 articles screened, 18 articles were included for further analyzation. One article studied discarded human tissue; others were studies conducted on rats, pigs, or dogs. Perfusion periods varied from 1 h to 10 d; eight articles also described replantation. Risk of bias was generally scored high; none of the articles was excluded based on these scores. Tissue vitality showed overall better results in the perfused groups, more pronounced when perfusing over 6 h. The development of edema was a broadly described side effect of perfusion. CONCLUSIONS: Although tissue vitality outcomes seem to favor extracorporeal perfusion, this is difficult to objectify because of large heterogeneity and poor quality of the available evidence. Future research should focus on validating outcome measures, edema prevention, perfusion settings, and maximum perfusion time for safe replantation and be preferably performed on large animals to increase translation to clinical settings.

Peri-operative care for patients undergoing lymphaticovenular anastomosis: A systematic review.

BACKGROUND: Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that involves the anastomosis of a functional lymphatic channel to a venule. Although peri-operative care might be an important contributor to the success of this technique, evidence about optimal peri-operative care seems limited. This review aims to summarize the peri-operative methods used by authors reporting on LVA. METHODS: A systematic search of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Peri-operative care used by authors was summarized and listed in a pre-defined form. Studies were also graded on quality of evidence by the GRADE system and a lymphedema surgery-specific system. RESULTS: In total, 22 studies were identified describing peri-operative measures. Although most authors were sparse in their description of peri-operative management, most recommended initiation of conventional compression therapy at 1-4 weeks after surgery. Prophylactic antibiotics, elevation of the affected limb, bandaging, low-molecular-weight heparin, prostaglandin E1, and manual pressure therapy were also described. The quality of evidence of the included studies was low on average. CONCLUSION: Although supermicrosurgical LVAs are gaining in popularity, there are no high-quality prospective trials evaluating these new techniques and the description of peri-operative management is scarce. Of the available studies, a peri-operative management consisting of prophylactic antibiotics, elevation of the affected limb during night and hospital stay, and compression therapy 4 weeks post-surgery for 6 months seems to be preferred. Future studies should describe a detailed peri-operative protocol to allow for a better comparison between study results and to determine optimal peri-operative recommendations.

Lymphovenous Anastomosis and Secondary Resection for Noonan Syndrome with Vulvar Lymphangiectasia.

In this case report we describe the use of a 2-stage approach to treat severe recurrent vulvar lymphangiectasia in a patient with Noonan syndrome. First, 3 functional lymphatic vessels were identified and anastomosed to venules in an end-to-end fashion. Then, in a second surgical procedure, the vulvar lesions were resected as much as possible and the vulva was reconstructed. By the 12-month follow-up the patient had recovered well. Although there were still some small vesicles on the left labia there was no more ooze, itch, and pain. Lymphatic mapping using indocyanine green showed improvement of the edema of her vulva region and patent LVA. In addition to the demonstration of this 2-stage approach, this case report also demonstrates the benefits of preemptive LVA before performing surgery that may be at high risk for postoperative lymph edema.