Download PDF
CC BY-NC 4.0 · Arch Plast Surg 2021; 48(03): 246-253
DOI: 10.5999/aps.2020.02432
Breast/Trunk
Review Article

Patient-specific surgical options for breast cancer-related lymphedema: technical tips

Jin Geun Kwon 
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Dae Won Hong
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Hyunsuk Peter Suh 
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Changsik John Pak
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Joon Pio Hong 
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
› Author Affiliations
› Further Information
   Permissions and Reprints

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

Keywords

Lymphedema - Breast cancer lymphedema - Lymphaticovenous anastomosis - Lymph node transfer


Publication History

Received: 11 December 2020

Accepted: 09 April 2021

Article published online:
21 March 2022

© 2021. The Korean Society of Plastic and Reconstructive Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonCommercial License, permitting unrestricted noncommercial use, distribution, and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes. (https://creativecommons.org/licenses/by-nc/4.0/)

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Comment to this article:

Commentary: Patient-specific Surgical Options for Breast Cancer-related Lymphedema: Technical TipsArch Plast Surg 2021; 48(03): V2-V2
DOI: 10.1055/s-0043-1777246

 

  • REFERENCES

  • 1 DiSipio T, Rye S, Newman B. et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol 2013; 14: 500-15
    CrossrefPubMedSearch in Google Scholar
  • 2 Gillespie TC, Sayegh HE, Brunelle CL. et al. Breast cancerrelated lymphedema: risk factors, precautionary measures, and treatments. Gland Surg 2018; 7: 379-403
    CrossrefPubMedSearch in Google Scholar
  • 3 Masia J, Pons G, Nardulli ML. Combined surgical treatment in breast cancer-related lymphedema. J Reconstr Microsurg 2016; 32: 16-27
    PubMedSearch in Google Scholar
  • 4 Schaverien MV, Coroneos CJ. Surgical treatment of lymphedema. Plast Reconstr Surg 2019; 144: 738-58
    CrossrefPubMedSearch in Google Scholar
  • 5 Chang DW, Masia J, Garza 3rd R. et al. Lymphedema: surgical and medical therapy. Plast Reconstr Surg 2016; 138 (Suppl. 03) 209S-218S
    CrossrefPubMedSearch in Google Scholar
  • 6 Cha HG, Oh TM, Cho MJ. et al. Changing the paradigm: lymphovenous anastomosis in advanced stage lower extremity lymphedema. Plast Reconstr Surg 2021; 147: 199-207
    CrossrefPubMedSearch in Google Scholar
  • 7 Cho MJ, Kwon JG, Pak CJ. et al. The role of duplex ultrasound in microsurgical reconstruction: review and technical considerations. J Reconstr Microsurg 2020; 36: 514-21
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Forte AJ, Boczar D, Kassis S. et al. Use of magnetic resonance imaging for evaluation of therapeutic response in breast cancer-related lymphedema: a systematic review. Arch Plast Surg 2020; 47: 305-9
    Thieme ConnectPubMedSearch in Google Scholar
  • 9 Suami H, Scaglioni MF. Anatomy of the lymphatic system and the lymphosome concept with reference to lymphedema. Semin Plast Surg 2018; 32: 5-11
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Hara H, Mihara M, Seki Y. et al. Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema. Plast Reconstr Surg 2013; 132: 1612-8
    CrossrefPubMedSearch in Google Scholar
  • 11 AlJindan FK, Lin CY, Cheng MH. Comparison of outcomes between side-to-end and end-to-end lymphovenous anastomoses for early-grade extremity lymphedema. Plast Reconstr Surg 2019; 144: 486-96
    CrossrefPubMedSearch in Google Scholar
  • 12 Pereira N, Lee YH, Suh Y. et al. Cumulative experience in lymphovenous anastomosis for lymphedema treatment: the learning curve effect on the overall outcome. J Reconstr Microsurg 2018; 34: 735-41
    Thieme ConnectPubMedSearch in Google Scholar
  • 13 Iyer D, Jannaway M, Yang Y. et al. Lymphatic valves and lymph flow in cancer-related lymphedema. Cancers (Basel) 2020; 12: 2297
    CrossrefPubMedSearch in Google Scholar
  • 14 Olszewski WL. Contractility patterns of human leg lymphatics in various stages of obstructive lymphedema. Ann N Y Acad Sci 2008; 1131: 110-8
    CrossrefPubMedSearch in Google Scholar
  • 15 Seki Y, Kajikawa A, Yamamoto T. et al. The dynamic-lymphaticovenular anastomosis method for breast cancer treatment-related lymphedema: creation of functional lymphaticovenular anastomoses with use of preoperative dynamic ultrasonography. J Plast Reconstr Aesthet Surg 2019; 72: 62-70
    CrossrefPubMedSearch in Google Scholar
  • 16 Kataru RP, Wiser I, Baik JE. et al. Fibrosis and secondary lymphedema: chicken or egg?. Transl Res 2019; 209: 68-76
    CrossrefPubMedSearch in Google Scholar
  • 17 Ly CL, Kataru RP, Mehrara BJ. Inflammatory manifestations of lymphedema. Int J Mol Sci 2017; 18: 171
    CrossrefPubMedSearch in Google Scholar
  • 18 Sapountzis S, Nicoli F, Chilgar R. et al. Evidence-based analysis of lymph node transfer in postmastectomy upper extremity lymphedema. Arch Plast Surg 2013; 40: 450-1
    Thieme ConnectPubMedSearch in Google Scholar
  • 19 Suh HSP, Jeong HH, Choi DH. et al. Study of the medial superficial perforator of the superficial circumflex iliac artery perforator flap using computed tomographic angiography and surgical anatomy in 142 patients. Plast Reconstr Surg 2017; 139: 738-48
    CrossrefPubMedSearch in Google Scholar
  • 20 Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg 2015; 135: 277-85
    CrossrefPubMedSearch in Google Scholar
  • 21 Goh TLH, Park SW, Cho JY. et al. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap: a review of 210 cases. Plast Reconstr Surg 2015; 135: 592-601
    CrossrefPubMedSearch in Google Scholar
  • 22 Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg 2013; 71: 380-3
    CrossrefPubMedSearch in Google Scholar
  • 23 Peter Suh HS, Hong JP. Effects of incisional negative-pressure wound therapy on primary closed defects after superficial circumflex iliac artery perforator flap harvest: randomized controlled study. Plast Reconstr Surg 2016; 138: 1333-40
    CrossrefPubMedSearch in Google Scholar
  • 24 Lee KT, Lim SY, Pyun JK. et al. Improvement of upper extremity lymphedema after delayed breast reconstruction with an extended latissimus dorsi myocutaneous flap. Arch Plast Surg 2012; 39: 154-7
    Thieme ConnectPubMedSearch in Google Scholar