“The Uncertainty Principle”– studying immediate lymphatic reconstruction impacts the natural history of breast cancer related lymphedema

Breast cancer-related lymphedema (BCRL) following axillary lymph node dissection (ALND) is a life-altering sequela for patients and a challenging problem for their surgeons. In order to prevent BCRL, immediate lymphatic reconstruction (ILR) is a surgical technique that has been devised to restore lymphatic drainage to the operative limb. Although ILR is becoming popular in the literature, we have identified several challenges within our own ILR research, including a lack of a clear definition of lymphedema, a lack of common outcome measures and possible alteration of the natural history of lymphedema through early compression therapy. Given these challenges, we must move forward with caution, while striving to develop clear and universally agreed upon definitions and outcomes, so that we can advance the body of evidence in support of ILR

Mitigating Breast-Cancer-Related Lymphedema—A Calgary Program for Immediate Lymphatic Reconstruction (ILR)

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses

Mitigating Breast-Cancer-Related Lymphedema—A Calgary Program for Immediate Lymphatic Reconstruction (ILR)

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses

Acceptance of outpatient enhanced recovery after surgery (ERAS©) protocols for implant-based breast reconstruction nudged on by the COVID-19 pandemic

We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018–March 2020) and during the pandemic (DP; April 2020–March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings

Higher Rate of Lymphedema with Inguinal versus Axillary Complete Lymph Node Dissection for Melanoma: A Potential Target for Immediate Lymphatic Reconstruction?

Background: The present study was conducted to define the lymphedema rate at our institution in patients undergoing axillary (ALND) or inguinal (ILND) lymph node dissection (LND) for melanoma. It aimed to examine risk factors predisposing patients to a higher rate of lymphedema, highlighting which patients could be targeted for immediate lymphatic reconstruction (ILR). Methods: A retrospective chart review was conducted between October 2015 and July 2020 to identify patients who had undergone ALND or ILND for melanoma. The main outcome measures were rates of transient and permanent lymphedema. Univariate and multivariate analyses were performed to assess the relationship between lymphedema rate and factors related to patient characteristics, surgical procedure, pathology findings, and adjuvant treatment. Results: Between October 2015 and July 2020, 66 patients underwent LND for melanoma: 34 patients underwent ALND and 32 patients underwent ILND. At a median follow-up of 29 months, 85.3% (n = 29) of patients having had an ALND did not experience lymphedema, versus 50.0% (n = 16) of ILND (p = 0.0019). The rates of permanent lymphedema for patients having undergone ALND and ILND were 11.8% (n = 4) and 37.5% (n = 12) respectively (p = 0.016, NS). The rate of transient lymphedema was 2.9% (n = 1) for ALND and 12.5% (n = 4) for ILND (p = 0.13, NS). On univariate analysis, the location of LND and wound infection were found to be significant factors for lymphedema. On multivariate analysis, only the location of LND remained a significant predictor, with the inguinal location predisposing to lymphedema. Conclusion: This study highlights the high rate of lymphedema following ILND for melanoma and is a potential target for future patients to be considered for ILR

Gathering Dust—Resistance to Simulator-based Deliberate Practice in Microsurgical Training

Background Despite unrestricted access to a simulated microsurgery model, learners have not consistently self-regulated their learning by completing practice. This paper explores the lived experience of learners regarding how practice is perceived and why it is resisted

Incidental Internal Mammary Nodes during Recipient Vessel Dissection in Breast Reconstruction: Are They Significant?

Summary: Internal mammary (IM) lymph nodes may be exposed during recipient vessel preparation in free-flap breast reconstruction, and in rare cases, positivity of these nodes may affect treatment in patients with breast cancer. This systematic review examines the incidence and significance of IM nodes identified by plastic surgeons. Eligibility criteria included free-flap breast reconstruction with concurrent IM node biopsy. Data were analyzed for incidence of IM node biopsy and nodal positivity. Ten studies met inclusion criteria, with a total of 2055 patients and 717 nodes submitted to pathology. Incidence of IM positivity ranged approximately from 1% to 11%, for a calculated gross overall incidence of 2.9%. Of 59 patients with a positive IM node, 50 patients received additional adjuvant therapy, with insufficient data to determine the effect of treatment on survival