BACKGROUND:The authors introduce the technique of reverse lymphatic mapping for vascularized lymph node transfer. This physiologic technique allows one to identify which lymph nodes drain the trunk ...as opposed to the extremity, to minimize the risk of iatrogenic lymphedema.
METHODS:A prospective study of patients undergoing vascularized lymph node transfer using the reverse lymphatic mapping technique was conducted. Patients received technetium injections in the first and second webspaces of the foot and intradermal indocyanine green injections in the lower abdomen. Lymphatic vessels were traced to the lymph nodes draining the lower abdomen that were harvested; a gamma probe was used to localize lymph nodes draining the lower extremity, which were avoided. In cases of vascularized axillary lymph node transfer, technetium was injected into the hand and indocyanine green was injected into the back and lateral chest. Ten-second counts were recorded of the lymph node flap and the sentinel node draining the extremity for comparison.
RESULTS:Thirty-five patients underwent vascularized lymph node transfer (19 groin and 16 axillary lymph node transfers) guided by reverse lymphatic mapping. Follow-up time was 1 to 30 months. Mean 10-second count using the gamma probe for all lymph node flaps was 88.6 (SD, 123; median, 39); mean 10-second count of extremity sentinel nodes was 2462 (SD, 2115; median, 2000). On average, 10-second signal strength of the lymph node flap was 6.0 percent that of the extremity sentinel node.
CONCLUSION:Reverse lymphatic mapping guides vascularized lymph node flap harvest based on physiologic drainage patterns of the trunk and limb that may minimize the risk of iatrogenic lymphedema.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
Lymphedema affects up to 1 in 6 patients who undergo treatment for a solid tumor in the United States. Its prevalence has increased as more effective oncologic therapies have improved patient ...survival, but there remains no definitive cure. Recent research has elucidated new details in the pathogenesis of the disease and has demonstrated that it is fundamentally an immunologic process that ultimately results in inflammation, fibroadipose deposition, impaired lymphangiogenesis, and dysfunctional lymphatic pumping. These findings have allowed for the development of novel medical and surgical therapies that may potentially alter the standard of care for a disease that has largely been treated by compression. This review seeks to provide an overview of the emerging therapies and how they can be utilized for effective management of lymphedema.
Lower Extremity Free Flaps for Breast Reconstruction Dayan, Joseph H; Allen, Robert J
Plastic and reconstructive surgery (1963),
2017-November, 2017-Nov, 2017-11-00, 20171101, Letnik:
140, Številka:
5S Advances in Breast Reconstruction
Journal Article
Recenzirano
Thigh-based flaps are typically a secondary option for breast reconstruction because of concerns regarding limited tissue volume and donor-site morbidity. In recent years, there have been a number of ...new techniques and insights that have resulted in greater flexibility and improved outcomes. This article reviews lessons learned from a large collective experience using the following 4 flapstransverse upper gracilis also known as transverse myocutaneous gracilis, diagonal upper gracilis, profunda artery perforator, and lateral thigh perforator flaps. Flap selection considerations include the patient’s fat distribution and skin laxity, perforator anatomy, and scar location. Pearls to minimize donor-site morbidity include avoiding major lymphatic collectors in the femoral triangle and along the greater saphenous vein and respecting the limits of flap dimension to reduce wound healing complications and distal ischemia. Limited flap volume may be addressed with stacking another flap from the contralateral thigh or primary fat grafting as opposed to overaggressive flap harvest from a single thigh. A detailed review of the benefits and disadvantages of each flap and strategies to improve results is discussed. With careful planning and selection, thigh-based flaps can provide a reliable option patients desiring autologous breast reconstruction.
OBJECTIVE:To better understand the long-term patient-reported outcomes (PROs) in satisfaction and health-related quality of life (QOL) following post-mastectomy reconstruction (PMR) using the ...BREAST-Q, comparing PROs from patients undergoing implant-based breast reconstruction (IBR) or autologous breast reconstruction (ABR).
SUMMARY OF BACKGROUND DATA:Multiple studies have demonstrated growth in mastectomy rates and concurrent increase in PMR utilization. However, most studies examining PMR PROs focus on short postoperative time periods—mainly within 2 years.
METHODS:BREAST-Q scores from IBR or ABR patients at a tertiary center were prospectively collected from 2009 to 2017. Mean scores and standard deviations (SDs) were calculated for satisfaction with breast, satisfaction with outcome, psychosocial well-being, physical well-being of the chest, and sexual well-being. Satisfaction with breasts and physical well-being of the chest were compared using regression models at postoperative years 1, 3, 5, and 7.
RESULTS:Overall, 3268 patients were included, with 336 undergoing ABR and 2932 undergoing IBR. Regression analysis demonstrated that ABR patients had greater postoperative satisfaction with breast scores at all timepoints compared with IBR patients. Postoperative radiation and mental illness adversely impacted satisfaction with breast scores. Furthermore, mental illness impacted physical wellbeing of the chest at all timepoints. IBR patients had satisfaction scores that remained stable over the study period.
CONCLUSION:This study presents the largest prospective examination of PROs in PMR to date. Patients who opted for ABR had significantly higher satisfaction with their breast and QOL at each assessed time point, but IBR patients had stable long-term satisfaction and QOL postoperatively.
BACKGROUND:Enhanced recovery pathways (ERPs) have been shown to aid in patient recovery and improve outcomes in many surgical settings. At present, there is limited data available regarding the use ...and feasibility of ERPs for patients undergoing microsurgical breast reconstruction. We sought to assess patient outcomes before and after the introduction of an ERP that was adopted by multiple surgeons at a single cancer center.
METHODS:A multidisciplinary ERP was developed for patients undergoing deep inferior epigastric perforator (DIEP) or muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Core elements of the ERP included substituting intravenous patient-controlled analgesia with a multimodal pain regimen consisting of intravenous ketorolac and transversus abdominis plane blocks with liposomal bupivacaine, as well as the use of intraoperative goal-directed fluid management. Patients who underwent surgery between April and August 2015 using the ERP were compared with a historical control cohort. The primary endpoints were hospital length of stay (LOS) and total postoperative opioid consumption.
RESULTS:In total, 91 consecutive patients were analyzed (ERP, 42; pre-ERP, 49). Mean hospital LOS was significantly shorter in the ERP group than in the pre-ERP group (4.0 vs. 5.0 days; p<0.0001). Total postoperative morphine equivalent consumption was also lower in the ERP group (46.0 vs. 70.5 mg; p=0.003). There was no difference in the incidence of 30-day complications between the groups (p=0.6).
CONCLUSIONS:The adoption of an ERP for DIEP and TRAM flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced LOS by 1 day.
Lymphedema is a progressive disease of the lymphatic system arising from impaired lymphatic drainage, accumulation of interstitial fluid, and fibroadipose deposition. Secondary lymphedema resulting ...from cancer treatment is the most common form of the disease in developed countries, affecting 15% to 40% of patients with breast cancer after lymph node dissection. Despite recent advances in microsurgery, outcomes remain variable and, in some cases, inadequate. Thus, development of novel treatment strategies is an important goal. Research over the past decade suggests that lymphatic injury initiates a chronic inflammatory response that regulates the pathophysiology of lymphedema. T-cell inflammation plays a key role in this response. In this review, the authors highlight the cellular and molecular mechanisms of lymphedema and discuss promising preclinical therapies.
Purpose:
While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate ...the safety and efficacy of VLNT using all available outcome measures.
Methods:
This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis.
Results:
There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema.
Conclusions:
VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.
BACKGROUND:Fat accumulation is frequently observed in patients with lymphedema but is not accounted for in existing staging systems. In addition, the specific regional patterns of fat and fluid ...accumulation remain unknown and might affect outcomes following medical or surgical intervention. The purpose of this study was to evaluate fluid and fat distribution in patients with lower extremity lymphedema using magnetic resonance angiography.
METHODS:Magnetic resonance angiographic examinations of patients with lower extremity lymphedema were reviewed. Fluid-fat grade and location were assessed by three observers. Three-point scales were developed to grade fluid (0 = no fluid, 1 = reticular pattern of fluid, and 2 = continuous stripe of subcutaneous fluid) and fat (0 = normal, 1 = subcutaneous thickness less than twice that of the unaffected side, and 2 = subcutaneous thickness greater than twice that of the unaffected side) accumulation.
RESULTS:In total, 76 magnetic resonance angiographic examinations were evaluated. Using the proposed grading system, there was good interobserver agreement for fat and fluid accumulation location (91.5 percent; κ = 0.9), fluid accumulation grade (95.7 percent; κ = 0.95), and fat accumulation grade (87.2 percent; κ = 0.86). Patients with International Society of Lymphology stage 2 lymphedema had a wide range of fluid and fat grades (normal to severe). The most common location of fluid accumulation was the lateral lower leg, whereas the most common location of fat accumulation was the medial and lateral lower leg.
CONCLUSION:The proposed magnetic resonance angiographic grading system may help stratify patients with International Society of Lymphology stage 2 lymphedema on the basis of tissue composition.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Diagnostic, IV.
Prepectoral placement of tissue expanders for two-stage implant-based breast reconstruction potentially minimizes chest wall morbidity and postoperative pain. The authors explored 90-day clinical and ...health-related quality-of-life outcomes for prepectoral versus subpectoral tissue expander breast reconstruction.
The authors conducted a propensity score-matching analysis (nearest neighbor, 1:1 matching without replacement) of patients who underwent immediate prepectoral or subpectoral tissue expander breast reconstruction between December of 2017 and January of 2019. Matched covariates included age, body mass index, race/ethnicity, smoking status, chemotherapy, radiotherapy, nipple-sparing mastectomy, and laterality of reconstruction. Outcomes of interest were perioperative analgesia use, 90-day postoperative patient-reported pain, complication rates, and BREAST-Q physical well-being of the chest scores.
Of the initial cohort of 921 patients, 238 were propensity-matched and included in the final analysis. The matched cohort had no differences in baseline characteristics. Postoperative ketorolac (p = 0.048) use was higher in the subpectoral group; there were no other significant differences in intraoperative and postoperative analgesia use. Prepectoral patients had lower pain on postoperative days 1 to 2 but no differences on days 3 to 10. BREAST-Q physical well-being of the chest scores did not differ. Prepectoral patients had higher rates of seroma than subpectoral patients (p < 0.001). Rates of tissue expander loss did not differ.
This matched analysis of 90-day complications found lower early postoperative pain in prepectoral tissue expander patients but no longer-term patient-reported differences. Although prepectoral reconstruction patients experienced a higher rate of seroma, this did not translate to a difference in tissue expander loss. Long-term analysis of clinical and patient-reported outcomes is needed to understand the full profile of the prepectoral technique.
Therapeutic, III.
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