Intra-abdominal donors for vascularized lymph node transfer: an update and review

Lymphedema continues to be a very challenging clinical problem. While compression and physical therapy remain the foundation of treatment, recent advances in microsurgery and super-microsurgery have allowed for the development of promising surgical options. One of these options is vascularized lymph node transfer (VLNT), which has gained significant popularity over recent years. However, there is no consensus on the ideal donor lymph node basin for VLNT. In addition, the most commonly reported donor sites, including the groin, supraclavicular, submental, and lateral thoracic nodes, carry the risk of iatrogenic lymphedema and/or visible scarring. In order to avoid these risks, the use of intra-abdominal donor sites for VLNT has been pursued. This article reviews the reported techniques and outcomes for each of the intra-abdominal donor sites for VLNT

Reply : a prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema

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A Prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema

Background: The authors prospectively evaluated the efficacy of lymphovenous bypass in patients with lymphedema secondary to cancer treatment. Methods: The authors prospectively enrolled 100 consecutive patients with extremity lymphedema secondary to cancer treatment. Sixty-five patients underwent lymphovenous bypass with indocyanine green fluorescent lymphangiography. Evaluation included qualitative assessment and quantitative volumetric analysis before and 3, 6, and 12 months after bypass. Results: Lymphovenous bypass was performed in 89 upper extremities and 11 lower extremities. For upper extremity lymphedemas, the mean preoperative volume differential was 32 percent. Symptom improvement was reported by 96 percent of patients and quantitative improvement was noted by 74 percent. The overall mean volume differential reduction was 33 percent at 3 months, 36 percent at 6 months, and 42 percent at 12 months after surgery. The mean volume differential reductions at 3, 6, and 12 months after lymphovenous bypass in patients with stage 1 or 2 lymphedema (58, 52, and 61 percent, respectively) were significantly larger than those in the patients with stage 3 or 4 lymphedema (12, 16, and 17 percent, respectively). Eleven bypasses were performed in seven patients with lower extremity lymphedema, with a mean preoperative volume differential of 38 percent. Only four (57 percent) of these patients reported symptom improvement; postoperative volume measurements were available for only two of these four. Conclusions: Lymphovenous bypass can be effective in reducing lymphedema severity, particularly in patients with early-stage upper extremity lymphedema. Indocyanine green lymphangiography accurately identified functional lymphatic vessels and may have a role in objectively assessing lymphedema severity and patient selection.10 page(s

Using indocyanine green fluorescent lymphography to demonstrate lymphatic architecture

Background: Visualisation of the lymphatic system is a challenging task. Recently, an indocyanine green (ICG) fluorescent lymphography system was developed for visualising the lymphatic vessels. ICG emits energy in the near-infrared region between 840 and 850 nm when it is bound to protein in the tissue. Aim: To use ICG fluorescent lymphography to identify locations of the lymphatic vessel for lymphovenous shunt. Methods: The lymphatic anatomy in the upper extremity was investigated using ICG fluorescent lymphography in 3 healthy volunteers and 15 patients with breast cancer-related lymphoedema prior to them undergoing lymphaticovenular bypass. Results: In healthy volunteers, fluorescent images of lymphatic vessels emerged at the dorsal hand as a shiny linear pattern and ran longitudinally towards the proximal arm after a few minutes. In lymphoedema patients, the lymphatic vessels could be identified at the dorsal hand, but the appearance of the lymphatic structure varied between patients. Conclusions: ICG fluorescent lymphography allows for the prompt identification of the lymphatic vessels and has the potential to improve the outcomes of lymphovenous shunt operations and for use as a diagnostic tool.5 page(s

A comprehensive overview on the surgical management of secondary lymphedema of the upper and lower extremities related to prior oncologic therapies

Abstract Secondary lymphedema of the upper and lower extremities related to prior oncologic therapies, including cancer surgeries, radiation therapy, and chemotherapy, is a major cause of long-term morbidity in cancer patients. For the upper extremities, it is most commonly associated with prior oncologic therapies for breast cancer, while for the lower extremities, it is most commonly associated with oncologic therapies for gynecologic cancers, urologic cancers, melanoma, and lymphoma. Both non-surgical and surgical management strategies have been developed and utilized, with the primary goal of all management strategies being volume reduction of the affected extremity, improvement in patient symptomology, and the reduction/elimination of resultant extremity-related morbidities, including recurrent infections. Surgical management strategies include: (i) ablative surgical methods (i.e., Charles procedure, suction-assisted lipectomy/liposuction) and (ii) physiologic surgical methods (i.e., lymphaticolymphatic bypass, lymphaticovenular anastomosis, vascularized lymph node transfer, vascularized omental flap transfer). While these surgical management strategies can result in dramatic improvement in extremity-related symptomology and improve quality of life for these cancer patients, many formidable challenges remain for successful management of secondary lymphedema. It is hopeful that ongoing clinical research efforts will ultimately lead to more complete and sustainable treatment strategies and perhaps a cure for secondary lymphedema and its devastating resultant morbidities

Scalp and Calvarial Reconstruction

Over the past several decades, an improved understanding of the blood supply of local flaps, increased experience with tissue expansion, and the development of techniques for microsurgical transfer of distant flaps have greatly contributed to the ability of plastic surgeons to repair scalp defects. This article will review basic anatomy, principles, and pearls of reconstruction for simple to complex scalp defects. Included will be anatomic considerations, indications and contraindications for reconstruction, and an overview of reconstructive options

The anterolateral thigh free flap for skull base reconstruction

To assess outcomes of patients undergoing reconstruction after resection of skull base tumors with the anterolateral thigh (ALT) free flap. Case series with chart review. Thirty-four consecutive patients with cancers involving the skull base that underwent reconstruction with the ALT free flap between 2005 and 2008 were reviewed. The ALT free flap was successfully used to reconstruct two, five, and 17 anterior, lateral, and posterior skull base defects, respectively. In addition, six and four combined anterior-lateral and lateral-posterior defects, respectively, were reconstructed. The overall complication rate was 29 percent. There were no flap losses. Nerve grafts (n = 6) and fascial slings (n = 14) for facial reanimation were performed using the lateral femoral cutaneous nerve and fascia lata from the same donor site as the ALT free flap. By harvesting the flap and graft(s) simultaneously with the resection, an average of 3.0 hours per case was saved. The ALT free flap is a versatile, reliable flap that should be considered a first-line option for skull base reconstruction. Operative time is minimized by performing a simultaneous two-team approach to resection and reconstruction, and by harvesting nerve, vein, and fascial grafts from the same donor site as the flap