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Wound Healing WOUND HEALING Lymphedema: Surgical and Medical Therapy David W. Chang, MD, FACS Background: Secondary lymphedema is a dreaded complication that some- Jaume Masia, MD, PhD times occurs after treatment of malignancies. Management of lymphedema has Ramon Garza III, MD historically focused on conservative measures, including physical therapy and Roman Skoracki, MD, compression garments. More recently, surgery has been used for the treatment FRCSC, FACS of secondary lymphedema. Peter C. Neligan, MB, Methods: This article represents the experience and treatment approaches of FRCS, FRCSC, FACS 5 surgeons experienced in lymphatic surgery and includes a literature review Chicago, Ill.; Barcelona, Spain; in support of the techniques and algorithms presented. Columbus Ohio; and Seattle, Wash. Results: This review provides the reader with current thoughts and practices by experienced clinicians who routinely treat lymphedema patients. Conclusion: The medical and surgical treatments of lymphedema are safe and effective techniques to improve symptoms and improve quality of life in prop- erly selected patients. (Plast. Reconstr. Surg. 138: 209S, 2016.) ymphedema is a disease process that is char- combined with the development of new contrast acterized by insufficient drainage of intersti- agents, continue to improve diagnostic accuracy. Ltial fluid mostly involving the extremities. In Direct lymphangiography, a once practiced and the developed world, secondary lymphedema is now almost extinct method of visualizing the the most common type of lymphedema and may lymphatic channels from an extremity, is done be caused by trauma, infection, or most commonly using oil-based iodine contrast agents that are by oncologic therapy. It can be a dreaded and not directly injected into the lymphatics.1 Today, sev- uncommon complication from the treatment of eral other evaluation tools facilitate the diagnosis various cancers, particularly breast cancer, gyneco- of lymphedema and assist in surgical planning. logic cancers, melanomas, and other skin cancers Radionuclide lymphoscintigraphy has been the and urologic cancers. Cancer-related lymphedema gold standard for many years and is readily avail- affects cancer survivors on a daily basis and is a con- able in many centers. It involves the injection of a stant reminder of the cancer that they have fought filtered colloid, Technetium-99, subdermally into to overcome. Patients often complain of pain, the limb.1 The limb is then scanned. The Tech- heaviness, swelling, inability to find proper fitting necium is taken up by the lymphatics. Lymphos- clothing, and in some cases frequent infections. cintigraphy can assess the function of lymphatic We are just now beginning to better understand channels and drainage of lymph to nodal basins. the disease process, its diagnosis, and treatment It gives good information on the function of the options of secondary cancer-related lymphedema. lymphatic system and the function of the lymph node basins. Calculation of the transport index is EVALUATION OF THE LYMPHATIC SYSTEM Disclosure: The authors have no financial interest in The lymphatic system is a complex network any of the products, devices, or drugs mentioned in this article. The authors received book royalties from Elsevier of lymph vessels, lymphatic organs, and lymph and CRC Press. No external funding supported this work. nodes. The field of lymphatic imaging continues The authors have no conflicts of interest to declare. to evolve rapidly, and technological advances, From the University of Chicago Medicine and Biological Sci- Supplemental digital content is available for ences; the Hospital de la Santa Creu i Sant Pau; the Depart- this article. Direct URL citations appear in the ment of Plastic Surgery, The Ohio State University Medical text; simply type the URL address into any Web Center; and the University of Washington. browser to access this content. Clickable links Received for publication March 28, 2016; accepted June 17, to the material are provided in the HTML text 2016. of this article on the Journal’s Web site (www. Copyright © 2016 by the American Society of Plastic Surgeons PRSJournal.com). DOI: 10.1097/PRS.0000000000002683 www.PRSJournal.com 209S Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • September Supplement 2016 useful to semiquantitatively ascertain the severity the contrast enhancement of veins and eliminate of lymphedema and provide insight into any ana- these signals using novel techniques (Fig. 1).4 tomic abnormalities, such as areas of obstruction MRL is a good screening method to determine or a reduction in the number of visualized lym- whether a patient has functioning lymphatics, the phatic channels.2 It works by measuring the speed characteristics of the limb, and whether any nodal of uptake of the Technecium and how quickly it basins can be visualized. This can help guide the reaches the nodal basin. However, radionuclide- surgeon to choose the best possible procedure based imaging has the disadvantage of poor reso- for the patient, as patients with significant fibrosis lution, so it does not give good information on and minimal edema seen on MRL would likely not the anatomy of these lymphatic channels nor does benefit from the physiologic type of procedures. it quantify changes in the limb other than those Another emerging imaging modality is indo- related to the lymphatic system. It only provides cyanine green (ICG) lymphangiography, which sets of static images at 1 period in time, is time offers real-time visualization of lymphatic flow consuming, and generally does not aid in surgical and is helpful in patients who cannot undergo planning for lymphovenous anastomoses. It is also MRL because of either contrast allergies or metal an uncomfortable investigation for the patient. implants. Through the use of a near-infrared cam- Other modalities described below seem to be era, the fluorescence of ICG activated by a laser replacing lymphoscintigraphy for many patients. light source can be seen and the subdermal lym- Still, it can be useful to determine if there are phatic channels can be visualized. ICG lymphan- functional lymphatics in the affected extremity. giography can reveal the condition of lymphatic More recently, magnetic resonance lymphan- vessels in relation to the progression of lymph- giography (MRL) has been developed to provide edema and identify suitable channels that may be superior high-resolution anatomic images of the amenable to lymphatic surgery (Fig. 2). Different lymphatic system and detailed characterization patterns of diffusion of ICG can be used to grade of the soft tissue changes associated with lymph- the severity of lymphedema. The linear pattern is edema.3 It is possible to get detailed limb circum- normal, whereas splash, stardust, and diffuse pat- ference measurements from which limb volume terns indicate increasing severity of lymphedema can be calculated. To help distinguish lymphatic and increased levels of fibrosis in the lymphatic channels from veins, intravenous injection of feru- channels (Fig. 2).5 In fact, ICG is indispensable as moxytol can be performed during MRL to isolate a means of intraoperative imaging and planning. Fig. 1. (Left) Magnetic resonance venography without injection of intravenous ferumoxytol, dem- onstrating lymphatics and veins. (Right) Magnetic resonance lymphangiography of the same arm as (left) with injection of intravenous ferumoxytol, which allows suppression of the veins in the imaging study. 210S Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 138, Number 3S • Lymphedema Fig. 3. Mixed picture of lymphedema in the setting of venous insuf- ficiency, obesity (body mass index, 31 kg/m2), and lymphedema. patients. CDT (also known as complex physical therapy, comprehensive decongestive therapy, or decongestive lymphatic therapy) incorporates a multimodality approach, which includes manual lymphatic drainage, daily bandaging, exercise, and skin care.6 CDT is therapist directed. Lymphedema spe- cialists meet patients typically 5 times per week for a total of 6 weeks of intensive care. Patients are transitioned from this phase 1 therapy that focuses on volume reduction to a phase 2 therapy that focuses on maintenance. During phase 1, patients are taught to per- form exercises, perform self-directed manual lym- phatic drainage, and apply compression garments and wrapping. The lymphedema therapists per- form manual lymphatic drainage, apply compres- sion therapy, and take patients through a series Fig. 2. Indocyanin green lymphangiography: (above, left) linear of exercise to help prevent scar contractures and pattern; (above, right) splash pattern; (below, left) stardust pat- stiffness and improve posture. tern; (below, right) diffuse pattern. Phase 2 is mostly patient-directed care. Both phases involve meticulous skin and nail care. This A vascularized lymph node transfer (VLNT) can helps avoid minor trauma, which may lead to skin be done without ICG, whereas lymphaticovenular infections, such as erysipelas.7 anastomosis (LVA) cannot. There have been numerous studies that have evaluated the effectiveness of this labor and time MEDICAL AND NONSURGICAL intensive approach compared with compression MANAGEMENT bandages alone or physical exercise alone.6,8–11 Several studies have found no difference between Complete Decongestive Therapy CDT and less
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