Download PDF
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
1   Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
,
Chia-Yu Lin
1   Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
,
Ming-Huei Cheng
1   Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
› Author Affiliations
Further Information

Publication History

04 February 2014

08 April 2014

Publication Date:
19 August 2014 (online)

   Permissions and Reprints

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
 

  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar