From Theory to Evidence: Long-Term Evaluation of the Mechanism of Action and Flap Integration of Distal Vascularized Lymph Node Transfers

Ketan M. Patel; Chia-Yu Lin; Ming-Huei Cheng

doi:10.1055/s-0034-1381957

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2015; 31(01): 026-030
DOI: 10.1055/s-0034-1381957

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

From Theory to Evidence: Long-Term Evaluation of the Mechanism of Action and Flap Integration of Distal Vascularized Lymph Node Transfers

Ketan M. Patel

¹Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan

,

Chia-Yu Lin

¹Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan

,

Ming-Huei Cheng

¹Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan

› Author Affiliations

Abstract

Background Nonanatomic (distal) placement of vascularized lymph node (VLN) transfers have shown efficacy in the treatment of extremity lymphedema, but the mechanism by which these flaps provide relief of lymphedema remains unclear. Intrinsic lymphovenous connections have been previously shown to exist in the transferred flap. But, the long-term interaction of the VLN flap and surrounding lymphedematous extremity has not been previously investigated.

Patients and Methods A retrospective review of a prospective maintained database of patients who underwent VLN transfer was evaluated. Patients who underwent distal VLN transfer and had more than 1-year follow-up were identified. Lymphodynamic evaluation was performed using 0.3 to 0.6 mL indocyanine green (ICG) injection at 5 cm proximal to the flap edge on identified patients. Migration direction of dye and latency period was evaluated.

Results In total, 20 patients were identified who met inclusion criteria. Average long-term follow-up was 27.3 months. The average circumference reduction of the affected extremity was 40.5%. ICG appearance within the VLN flap was found in all patients occurring on average in 178.3 seconds. In all cases, flow occurred in the distal direction (toward the flap) with proximal placement of dye. Latency period was found to inversely correlate with circumference reduction (p < 0.01).

Conclusions Distal, nonanatomic placement of VLN flaps provide sustained limb circumference reduction in extremity lymphedema patients following a minimum of 1-year postoperatively. Flap integration with the recipient site reliably occurs as witnessed with consistent ICG drainage, and occurs in the gravity-dependent direction. Faster clearance of ICG will result in improved clinical limb circumference reduction.

Keywords

vascularized lymph node transfer - lymphedema - lymphatic microsurgery - lymphedema surgery - indocyanine green

Full Text

References

References
1 Can J, Cai R, Li S, Zhang D. Experimental study of lymph node auto-transplantation in rats. Chin Med J (Engl) 1998; 111 (3) 239-241
2 Lähteenvuo M, Honkonen K, Tervala T , et al. Growth factor therapy and autologous lymph node transfer in lymphedema. Circulation 2011; 123 (6) 613-620
3 Rabson JA, Geyer SJ, Levine G, Swartz WM, Futrell JW. Tumor immunity in rat lymph nodes following transplantation. Ann Surg 1982; 196 (1) 92-99
4 Shesol BF, Nakashima R, Alavi A, Hamilton RW. Successful lymph node transplantation in rats, with restoration of lymphatic function. Plast Reconstr Surg 1979; 63 (6) 817-823
5 Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results following microsurgical lymph node transplantation. Ann Surg 2006; 243 (3) 313-315
6 Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P, Suominen EA. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg 2012; 255 (3) 468-473
7 Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2013; 131 (6) 1286-1298
8 Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg 2013; . e-pub ahead of print DOI: 10.1097/SAP.0b013e31827fb39e
9 Lin CH, Ali R, Chen SC , et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg 2009; 123 (4) 1265-1275
10 Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg 2011; 67 (6) 589-593
11 Cheng MH, Huang JJ, Nguyen DH , et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol 2012; 126 (1) 93-98
12 Althubaiti GA, Crosby MA, Chang DW. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg 2013; 131 (1) 133e-135e
13 Cheng MH, Huang JJ, Wu CW , et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014; 133 (2) 192e-198e
14 Chen HC, O'Brien BM, Rogers IW, Pribaz JJ, Eaton CJ. Lymph node transfer for the treatment of obstructive lymphoedema in the canine model. Br J Plast Surg 1990; 43 (5) 578-586
15 Tobbia D, Semple J, Baker A, Dumont D, Johnston M. Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema. Plast Reconstr Surg 2009; 124 (3) 777-786
16 Stanton AW, Modi S, Mellor RH, Levick JR, Mortimer PS. Recent advances in breast cancer-related lymphedema of the arm: lymphatic pump failure and predisposing factors. Lymphat Res Biol 2009; 7 (1) 29-45
17 Mihara M, Hara H, Hayashi Y , et al. Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy. PLoS ONE 2012; 7 (7) e41126
18 Hara H, Mihara M, Seki Y, Todokoro T, Iida T, Koshima I. Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema. Plast Reconstr Surg 2013; 132 (6) 1612-1618
19 Modi S, Stanton AW, Svensson WE, Peters AM, Mortimer PS, Levick JR. Human lymphatic pumping measured in healthy and lymphoedematous arms by lymphatic congestion lymphoscintigraphy. J Physiol 2007; 583 (Pt 1) 271-285
20 Suami H, Pan WR, Taylor GI. Changes in the lymph structure of the upper limb after axillary dissection: radiographic and anatomical study in a human cadaver. Plast Reconstr Surg 2007; 120 (4) 982-991
21 Mihara M, Hara H, Iida T , et al. Antegrade and retrograde lymphatico-venous anastomosis for cancer-related lymphedema with lymphatic valve dysfuction and lymphatic varix. Microsurgery 2012; 32 (7) 580-584