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CC BY 4.0 · Arch Plast Surg 2024; 51(05): 504-509
DOI: 10.1055/a-2336-0150
Extremity/Lymphedema: Idea and Innovation

Distally Based Lymphatic Microsurgical Preventive Healing Approach—A Modification of the Classic Approach

Allen Wei-Jiat Wong 
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
6   Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taipei, Taiwan
,
Nadia Hui Shan Sim
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
,
Coeway Boulder Thing 
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
,
Wenxuan Xu
3   Toulouse School of Economics, Université Toulouse 1 Capitole, Toulouse, France
,
Hui Wen Chua
4   Department of General Surgery, Breast Service, Sengkang General Hospital, Singapore
,
Sabrina Ngaserin
4   Department of General Surgery, Breast Service, Sengkang General Hospital, Singapore
,
Shermaine Loh
5   Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
,
Yee Onn Kok
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
2   Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
,
Jia Jun Feng
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
2   Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
,
Tan Woon Woon Pearlie
1   Plastic, Reconstructive & Aesthetic Surgery Service, Sengkang General Hospital, Singapore
2   Department of Plastic Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore
,
Benita Kiat-Tee Tan 
4   Department of General Surgery, Breast Service, Sengkang General Hospital, Singapore
› Author Affiliations Funding None.
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Abstract

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally—terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively (p = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

Keywords

lymphedema - breast cancer - microsurgery - lymphovenous anastomosis

Authors' Contributions

Conceptualization: A.W-J.W., N.H.S.S., H.W.C., S.N., Y.O.K., J.J.F., T.W.W.P., B.K-T.T.


Formal analysis: A.W-J.W., N.H.S.S., W.X.


Methodology: A.W-J.W., N.H.S.S., H.W.C., S.N., C.B.T., S.L.


Project administration: A.W-J.W., N.H.S.S., C.B.T., S.L.


Visualization: H.W.C., S.N., Y.O.K., J.J.F., T.W.W.P., B.K.-T.T.


Writing—original draft: A.W-J.W., N.H.S.S., W.X.


Writing—reviewing and editing: A.W-J.W., N.H.S.S., W.X.


Ethical Approval

This study was approved by CIRB and conducted in accordance with the principles of the Declaration of Helsinki, under SingHealth Institutional Review Board Reference 2022/2619.


Patient Consent

Informed consent was obtained from patients prior to publication of their clinical photos.




Publication History

Received: 05 December 2023

Accepted: 28 May 2024

Accepted Manuscript online:
30 May 2024

Article published online:
06 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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