A Comprehensive Approach to Posttraumatic Lymphedema Surgical Treatment

Abstract

Background Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema.

Methods A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year.

Results Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected.

Conclusion Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.

Keywords

lymphedema - posttraumatic lymphedema - SCIP flap - lymphovenous anastomosis - supermicrosurgery

Authors' Contributions

Conceptualization: N.P., V.O.; data curation: N.P.; writing, original draft: N.P.; writing, review and editing: N.P., V.O., R.R.

Ethical Approval

This study was approved by the Scientific Ethics Committee (Institutional Review Board [IRB] approval number: CEC/10/2021)

Patient Consent

Written patient consent was obtained for publication and academic purpose.

Publikationsverlauf

Eingereicht: 12. Dezember 2022

Angenommen: 28. März 2023

Artikel online veröffentlicht:
02. August 2023

• References

• 1 Szczesny G, Olszewski WL. The pathomechanism of posttraumatic edema of lower limbs: I. The effect of extravasated blood, bone marrow cells, and bacterial colonization on tissues, lymphatics, and lymph nodes. J Trauma 2002; 52 (02) 315-322
• 2 Bräutigam P, Földi E, Schaiper I, Krause T, Vanscheidt W, Moser E. Analysis of lymphatic drainage in various forms of leg edema using two compartment lymphoscintigraphy. Lymphology 1998; 31 (02) 43-55
• 3 Mostbeck A, Partsch H. [Isotope lymphography–possibilities and limits in evaluation of lymph transport]. Wien Med Wochenschr 1999; 149 (2–4): 87-91
• 4 van Zanten MC, Mistry RM, Suami H. et al. The lymphatic response to injury with soft-tissue reconstruction in high-energy open tibial fractures of the lower extremity. Plast Reconstr Surg 2017; 139 (02) 483-491
• 5 Pereira N, Cámbara Á, Kufeke M, Roa R. Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: a case report. Microsurgery 2019; 39 (04) 354-359
• 6 Pereira N, Cambara Á, Kufeke M, Roa R. Prevention and treatment of posttraumatic lymphedema by soft tissue reconstruction with lymphatic vessels free flap: an observational study. Ann Plast Surg 2021; 86 (04) 434-439
• 7 Yamamoto T, Iida T, Yoshimatsu H, Fuse Y, Hayashi A, Yamamoto N. Lymph flow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph flow reconstruction without lymph node transfer or lymphatic anastomosis. Plast Reconstr Surg 2018; 142 (03) 796-804
• 8 Yamamoto T, Yamamoto N, Kageyama T, Sakai H, Fuse Y, Tsukuura R. Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis. J Plast Reconstr Aesthet Surg 2021; 74 (10) 2604-2612
• 9 Chen WF, McNurlen M, Ding J. et al. Vascularized lymph vessel transfer for extremity lymphedema - is transfer of lymph node still necessary?. Int Microsurg J 2019; 3: 1-7
• 10 Ciudad P, Chen WF. Preoperative indocyanine green lymphographic planning for dorsal metatarsal vascularized lymph vessel transfer in the treatment of upper extremity lymphedema. Microsurgery 2021; 41 (04) 391-392
• 11 Koshima I, Narushima M, Mihara M. et al. Lymphadiposal flaps and lymphaticovenular anastomoses for severe leg edema: functional reconstruction for lymph drainage system. J Reconstr Microsurg 2016; 32 (01) 50-55
• 12 Gentileschi S, Servillo M, Garganese G. et al. The lymphatic superficial circumflex iliac vessels deep branch perforator flap: a new preventive approach to lower limb lymphedema after groin dissection-preliminary evidence. Microsurgery 2017; 37 (06) 564-573
• 13 Mihara M, Tange S, Hara H, Han Peng Z, Haragi M, Muarai N. Modified lymph vessel flap transplantation for the treatment of refractory lymphedema: a case report. Microsurgery 2016; 36 (08) 695-699
• 14 Yamamoto T, Daniel BW, Rodriguez JR. et al. Radical reduction and reconstruction for male genital elephantiasis: superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg 2022; 75 (02) 870-880
• 15 Pons G, Masia J, Loschi P, Nardulli ML, Duch J. A case of donor-site lymphoedema after lymph node-superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg 2014; 67 (01) 119-123
• 16 Szczesny G, Olszewski WL. The pathomechanism of posttraumatic edema of the lower limbs: II–changes in the lymphatic system. J Trauma 2003; 55 (02) 350-354
• 17 General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent 2014; 81 (03) 14-18
• 18 Pereira N, Venegas J. Augmented reality microsurgical planning with a smartphone for lymphovenous anastomosis. Plast Reconstr Surg 2019; 144 (05) 955e-956e
• 19 Suami H, Taylor GI, Pan W-R. The lymphatic territories of the upper limb: anatomical study and clinical implications. Plast Reconstr Surg 2007; 119 (06) 1813-1822
• 20 Pan WR, Wang DG, Levy SM, Chen Y. Superficial lymphatic drainage of the lower extremity: anatomical study and clinical implications. Plast Reconstr Surg 2013; 132 (03) 696-707
• 21 Pereira N, Parada L, Kufeke M, Troncoso E, Roa R. A new planning method to easily harvest the superficial circumflex iliac artery perforator flap. J Reconstr Microsurg 2020; 36 (03) 165-170
• 22 Pereira N, Kufeke M, Parada L. et al. Augmented reality microsurgical planning with a smartphone (ARM-PS): a dissection route map in your pocket. J Plast Reconstr Aesthet Surg 2019; 72 (05) 759-762
• 23 Pereira N, Venegas J, Cifuentes I. Quality of life in patients undergoing to surgical treatment of lymphedema. Linguistic validation and transcultural adaptation of Lymphedema Quality of Life Score (LeQOLiS). Rev Cir 2020; 72: 113-117
• 24 Yamamoto T, Yamamoto N, Sakai H. et al. Targeting reflux-free veins with a vein visualizer to identify the ideal recipient vein preoperatively for optimal lymphaticovenous anastomosis in treating lymphedema. Plast Reconstr Surg 2018; 142 (05) 804e-806e
• 25 Brorson H, Höijer P. Standardised measurements used to order compression garments can be used to calculate arm volumes to evaluate lymphoedema treatment. J Plast Surg Hand Surg 2012; 46 (06) 410-415
• 26 Minasian RA, Samaha Y, Brazio PS. Post-traumatic lymphedema: review of the literature and surgical treatment options. Plast Aesthet Res 2022; 9: 18-27
• 27 Chepelenko GV. [Lymphography in posttraumatic edema of the leg]. Vestn Rentgenol Radiol 1986; 3 (03) 55-61
• 28 Chepelenko GV. [Clinical lymphographic diagnosis of posttraumatic edema in the substitution of bone defects]. Vestn Khir Im I I Grek 1987; 138 (04) 36-38
• 29 Lohrmann C, Pache G, Felmerer G, Foeldi E, Schaefer O, Langer M. Posttraumatic edema of the lower extremities: evaluation of the lymphatic vessels with magnetic resonance lymphangiography. J Vasc Surg 2009; 49 (02) 417-423
• 30 Yamamoto T, Yamamoto N, Numahata T. et al. Navigation lymphatic supermicrosurgery for the treatment of cancer-related peripheral lymphedema. Vasc Endovascular Surg 2014; 48 (02) 139-143
• 31 Yamamoto T, Yamamoto N, Fuse Y, Narushima M, Koshima I. Optimal sites for supermicrosurgical lymphaticovenular anastomosis: an analysis of lymphatic vessel detection rates on 840 surgical fields in lower extremity lymphedema patients. Plast Reconstr Surg 2018; 142 (06) 924e-930e