Microlymphatic Surgery for the Treatment of Iatrogenic Lymphedema Corinne Becker, MDa, Julie V. Vasile, MDb,*, Joshua L. Levine, MDb, Bernardo N. Batista, MDa, Rebecca M. Studinger, MDb, Constance M. Chen, MDb, Marc Riquet, MDc KEYWORDS Lymphedema Treatment Autologous lymph node transplantation (ALNT) Microsurgical vascularized lymph node transfer Iatrogenic Secondary Brachial plexus neuropathy Infection KEY POINTS Autologous lymph node transplant or microsurgical vascularized lymph node transfer (ALNT) is a surgical treatment option for lymphedema, which brings vascularized, VEGF-C producing tissue into the previously operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Additionally, lymph nodes with important immunologic function are brought into the fibrotic and damaged tissue. ALNT can cure lymphedema, reduce the risk of infection and cellulitis, and improve brachial plexus neuropathies. ALNT can also be combined with breast reconstruction flaps to be an elegant treatment for a breast cancer patient. OVERVIEW: NATURE OF THE PROBLEM Clinically, patients develop firm subcutaneous tissue, progressing to overgrowth and fibrosis. Lymphedema is a result of disruption to the Lymphedema is a common chronic and progres- lymphatic transport system, leading to accumula- sive condition that can occur after cancer treat- tion of protein-rich lymph fluid in the interstitial ment. The reported incidence of lymphedema space. The accumulation of edematous fluid mani- varies because of varying methods of assess- fests as soft and pitting edema seen in early ment,1–3 the long follow-up required for diagnosing lymphedema. Progression to nonpitting and irre- lymphedema, and the lack of patient education versible enlargement of the extremity is thought regarding lymphedema.4 In one 20-year follow-up to be the result of 2 mechanisms: of patients with breast cancer treated with mastec- 1. The accumulation of lymph fluid leads to an tomy and axillary node dissection, 49% reported 5 inflammatory response, which causes increased the sensation of arm lymphedema. Of the patients fibrocyte activation. who developed lymphedema, 77% were diag- 2. Fat deposition occurs when malfunctioning nosed within the 3-year period following breast lymphatics are unable to transport fat mole- cancer treatment, and the remaining patients cules effectively.1 developed arm lymphedema at a rate of about a Department of Plastic Surgery, Lymphedema Centre, 6 Square Jouvenet, Paris 75016, France; b Department of Plastic Surgery, New York Eye and Ear Infirmary, 310 East 14th Street, New York, NY 10003, USA; c Department of Thoracic Surgery, European Hospital Georges Pompidou, 20 Rue Louis Leblanc, Paris 75908, France * Corresponding author. 1290 Summer Street, Suite 2200, Stamford, CT 06905. E-mail address: [email protected] Clin Plastic Surg 39 (2012) 385–398 http://dx.doi.org/10.1016/j.cps.2012.08.002 0094-1298/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved. plasticsurgery.theclinics.com 386 Becker et al 1% per year after the 3 years. Therefore, about a quarter of patients will develop lymphedema years after breast cancer treatment, and a long follow-up is required. The incidence of lymphedema after breast cancer treatment ranges from 24% to 49% after mastectomy and 4% to 28% after lumpectomy.1 Patients requiring more extensive breast cancer treatment with axillary node dissection and radia- tion have the greatest risk for the development of lymphedema. However, even the less extensive lymph dissection in sentinel node biopsy is asso- ciated with a 5% to 7% incidence of upper- extremity lymphedema.6 The incidence of lymphedema after treatment of other malignancies is reported as follows: 16% with melanoma, 20% with gynecologic cancers, 10% with genitourinary cancers, 4% with head and neck cancers, and 30% with sarcoma. Patients requiring pelvic dissection and radiation therapy for the treatment of non–breast cancer malignancies have a reported lymphedema rate of 22% and 31%, respectively.3 Risk factors for developing lymphedema after cancer treatment are obesity, infection, and trauma.1,5 In addition to the decreased amount of lymph tissue critical to a normal immune response, tissue changes and lymphostasis result in increased susceptibility to infection in the lymphedematous extremity. Clinically, patients may develop cellulitis from minor trauma that would otherwise be insig- Fig. 1. Leg cellulitis in a patient with congenital nificant in a normal extremity (Fig. 1). Each lymphedema. episode of infection further damages lymphatic channels and perpetuates a vicious cycle. Patients extremity to squeeze edema fluid out of the tissue may require lifelong antibiotic prophylaxis. and push the edema fluid proximally. Customized Lymphedema can also lead to erysipelas, lym- compression garments are subsequently placed phangitis, and evenlymphangiosarcoma. Erysipelas on the extremity to maintain the decreased is a streptococcal infection of the dermis. Lymphan- extremity size. Decongestive lymphatic therapy gitis is inflammation of the lymphatic channels as usually begins with intensive (daily for several a result of infection at a site distal to the channel, weeks) lymphatic massage and bandaging. This such asa paronychia, an insect bite, or an intradigital therapy is followed by less-frequent maintenance web space infection. Lymphangiosarcoma is a rare malignant tumor that occurs in long-standing cases of lymphedema (Fig.2).Stewart-Trevessyndrome is angiosarcoma arising from postmastectomy lym- phedema and has an extremely poor prognosis, with a median survival of 19 months.1 THERAPEUTIC OPTIONS FOR IATROGENIC LYMPHEDEMA Conservative Treatment Conservative lymphedema therapy is the backbone for providing symptomatic improvement of lymphe- dema and may slow the progression of disease. Multiple layers of short-elastic bandages are wrap- ped circumferentially around the lymphedematous Fig. 2. Lymphangiosarcoma. Treatment of Iatrogenic Lymphedema 387 lymphatic massage and daily placement of because lymphatic channel walls are thin, trans- compression garments for the rest of patients’ lives. parent, and very fragile. In addition, there may be Flare-ups of lymphedema may require repeating significant donor site morbidity. Lymphovenous the initial intensive daily lymphatic massage with anastomosis (LVA) connects an obstructed bandaging. Patients with severe lymphedema may lymphatic to a vein to shunt the lymph fluid into the require bandaging every night and wearing venous system and seem to be effective, especially compression garments everyday. in early stages of lymphedema.11,12 The LVA The major limitation of conservative therapy is remains patent if the lymphatic pressure is higher that reduction in extremity size is short lived than the venous pressure. Currently, a subdermal without continual compression; the maintenance vein is used because it has lower venous pressure. of compression (conservative therapy) is difficult The caliber of subdermal veins is less than a 1 to achieve long term because it is time consuming, mm, requiring supermicrosurgery with extrafine labor intensive, requires specialized therapists, microsurgical instruments and sutures. Usually, and requires commitment of patients and patients’ multipleLVAs(3–5)12,13 are createdto a lymphedem- support network. Frequently, it is difficult for atous extremity. Although in other centers, an patients to self-apply bandages. In addition, average of 9 LVAs (range of 5–18) are routinely insurance companies may inadequately cover created by teams of surgeons operating with therapists for bandaging and massage therapy, multiple microscopes simultaneously.14 requiring patients to parcel out therapy sessions. Autologous lymph node transplantation (ALNT),15–17 A second major limitation of conservative therapy also called microsurgical vascularized lymph node is that it cannot affect change in extremity girth transfer, is another reconstructive surgical treat- because of subcutaneous fat deposition and ment of lymphedema. This article focuses on fibrosis. Thus, surgical options for treatment have ALNT and its use in patients with secondary iatro- an important role in the treatment of lymphedema, genic lymphedema. In ALNT, a recipient bed in and a combination of treatment modalities may the lymphedematous extremity is prepared by rele- achieve the most improvement. asing scar tissue until healthy soft tissue is encoun- tered. Then a small flap containing superficial Surgical Treatment lymph nodes are harvested from a donor site with Surgical options for lymphedema treatment fall an artery and vein and microsurgically anasto- into 2 categories: debulking and physiologic. mosed to an artery and vein at the recipient site. Debulking procedures may involve elliptical The ALNT procedure is considered to be physio- wedge excision of excess skin and subcutaneous logic for several reasons. First, scar tissue, which tissue from an extremity or liposuction. Wedge may be blocking lymphatic flow, is released. excision of tissue can provide immediate symp- Second, healthy vascularized tissue in the form of tomatic relief to patients with severe lymphedema. a flap is brought into the previously operated site, Removal of heavy or hanging bulky tissue from an which may bridge lymphatic pathways through extremity can improve the function of the the scar tissue. Third, the flap contains healthy extremity7 and can also improve the