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- 亓发芝主任医师 教授
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医院:
复旦大学附属中山医院
科室:
整形外科
- 淋巴水肿的治疗
- 作者:亓发芝|发布时间:2010-08-02|浏览量:1640次
Treatment of upper Limb Lymphedema with Combination of Liposuction, Myocutaneous Flap Transfer and Lymph-fascia Grafting: An Preliminary Study
Fazhi Qi, M.D., Ph. D., Jianying Gu, M.D., Yuedong Shi, M.D. , Yanwen Yang, M.D.
Running title: Lymphedema treatment with myocutaneous flap and lymph-fascia graft上海市中山医院整形外科亓发芝
Corresponding Author:
Fazhi Qi, M.D., Ph. D.
Department of Plastic and Reconstructive Surgery,
Zhongshan Hospital, Fudan University,
Shanghai 200032, China
qi.fazhi@zs-hospital.sh.cn
Word count: 2237 words, with 1 Tables & 3 Figures
Abstract
Treatment of obstructive extremity lymphedema remains challenge in reconstructive surgery since none of varieties of procedures have been demonstrated a reliable resolution for the lymphedema. In this report we present the preliminary results of treatment of severe upper extremity lymphedema with combined liposuction, latissimus myocutaneous flap transfer and lymph-fascia grafting in 11 patients. All patients had histories of radical mastectomy, irradiation therapy for breast cancer, and frequent onsets of erysipelas. Postoperative measurements in an average of 26 months follow-up showed that significant decrease of circumferences of the arms on all levels at surgery side were achieved. The onsets of erysipelas were also reduced. There was no chronic lymphedema found in the donor leg after harvest of the lymph-fascia graft. The results suggest the strategy of liposuction, latissimus myocutaneous flap transfer and lymph-fascia grafting may provide a useful method for treatment of the chronic upper extremity lymphedema with severe axillary scar contracture.
Key words: Lymphedema, lymph-fascia graft, myocutaneous flap, liposuction
Introduction
Treatment of obstructive extremity lymphedema continuously poses a formidable challenge in reconstructive surgery.1-6 Clinically, most of obstructive lymphedema are caused by damage of lymph vessels and scar contracture due to surgical and irradiation treatment of malignant tumors or parasite infection. In the upper extremity, lymphedema is mostly the complication of the radical mastectomy for breast cancer. Pathologically, lymphedema is characterized by the accumulation of protein-rich lymph fluid in the subcutaneous tissue, which results in fatty tissue hypertrophy, fibrosis and lymphostatic elephantiasis. The signs of lymphostatic elephantiasis of lymphedema in the upper extremity are usually not as significant as in lower extremity, but similar treatment strategies are used for lymphedema of upper and lower extremities.4-11
Various procedures have been proposed for the treatment of extremity lymphedema. The non-surgical therapies include compression, massage, heating-and-bandage, and limb elevation.1,8-9 These conservative non-surgical therapies are used for the treatment of mild edema or as adjuvant treatment after surgical operation. The surgical treatments include surgical resection of edematous tissue,5 microvascular anastomosis between lymphatic and venous system, 1-3 lymph node transplantation,4 and liposuction.6-17 However, the results of those procedures were not consistent in the patients with severe lymphedema.
Clinical studies have shown that skin, muscle, and myocutaneous flaps and omentum flap may be used as a lymphatic bridge to reestablish lymphatic flow across an area of obstructive extremity lymphedema.21-27 In this report, we evaluate the preliminary results of treatment of severe post-mastectomy arm lymphedema with combined liposuction, latissmus myocutaneous flap transfer and lymph-fascia grafting. Use of lymph-rich fascia graft was based on observations of spontaneous regeneration or reconnection of lymphatic vessels after replantation or free flap transfer without performance of lymphatic vessel anastomosis.18-20
Patients and Methods
From February 2000 to September 2007, 11 patients with chronic lymphedema of upper extremities underwent combined liposuction, latissimus myocutaneous flap transfers with lymph-fascia tissue grafting. The ages of the patients ranged from 41 to 74 years old and the average duration of lymphedema was 8 years. All patients had history of radical mastectomy, axillary dissection and irradiation therapy for breast cancer. Only the patients who had significant axillary scar contracture and severe arm lymphedema were selected for the procedures. These selected patients had history of reiterative lymphangitis (erysipelas) and conservative non-surgical treatment showed no significant improvement of lymphedema symptoms. Most of the patients also had compromised shoulder movement. Some of them complained palm and/or finger numbness. The increase of circumference of the affected arms at the level of the middle of forearm ranged from 8 to 11 cm while compared with the contralateral normal arms in patients. The onsets of erysipelas were average 6.45 times per year in those patients.
Surgical Procedure
General anesthesia was induced in all cases. The surgical procedure included four steps.
Step one. The axillary scar contracture was released. The surrounding damaged skin by radiation therapy was also excised. In most patients, stone-like scar contracture in the axillary area was found, which was probably attributed to the previous irradiation therapy. Release of scar contracture would significantly improve the shoulder movement. Special attention should be paid to avoid damage of axillary blood vessels and nerves.
Step two. The arm was elevated for exsanguination. Tourniquet was then applied to reduce the bleeding. No tumescent fluid was injected. Through ten to fifteen 5 mm long skin incisions, fine cannulas were inserted into the subcutaneous space. The cannulas were connected to a vacuum pump with a negative 0.8 atmospheric pressure. Liposuction procedure started from the dorsum of the hand. The cannula was parallel with the long axial of the arm. Suctioned areas were subsequently compressed firmly with elastic bandage to reduce bleeding and postoperative swelling. After the elastic bandage was applied, the tourniquet was released and removed.
Step three. A skin incision was made from the inguina to the medial patella. The great sapheneous vein with its one side surrounding lymph vessels rich fascia were isolated and then harvested. The lymph-rich fascia graft including the great sapheneous vein was measured average 25 cm in length (ranged from 22 cm to 26 cm) and 1.0 cm in width. After the graft was harvested, the donor area was closed and drained with a tube connected to a negative pressure device. A subcutaneous tunnel was created from the medial side of the arm to the superior calvecular area. The fascia graft was inset through the tunnel to bridge the axillary area. The proximal and distal ends of fascia graft were fixed to soft tissue with stitches. No vascular anastomosis was performed.
Step four. The size of the axillary wound was measured when the arm was abducted. The latissimus dorsal myocutaneous pedicle flap was then raised and transferred for coverage of the axillary wound. The sizes of flaps ranged from 24 to 29 cm × 7 to 11 cm, which were designed with enough width and bulk for coverage of the wound without dead space. The wound was drained after coverage.
Elastic bandage was applied for arm compression for two weeks postoperatively. Then the patients were encouraged to routinely wear the custom-made compression garment. Postoperative follow-up ranged from 3 months to 60 months with average of 26 months. The outcomes were evaluated by measurement of arm circumferences and clinical observation for onsets of erysipelas.
The circumferences of the arms at surgery side were measured at the levels of the palm across thumb web, wrist, middle of forearm, elbow, middle of upper arm and proximal upper arm. The measurements were performed at each follow-up visit. The measurements of the contralateral arms were used as the control. The data on arm measurements were compared using student’s t-test. Statistical significance was assumed at p<0.05.
Results
All of flaps were survival without necrosis. Two patients had partial wound disruption in the axillary area. The wound healed 2 to 3 months after conservative wound treatment. Slight decrease of arm strength was found in one patient. Two patients complained of numbness in fingers, but no sensation loss was found. Dorsal foot edema of the donor leg was observed in one patient right after surgery. The edema was completely alleviated at 3 months postoperatively. Slight edema at medial side of knee was found in one patient, which lasted about 2 months after surgery. There was no chronic lymphedema found in the donor leg in all of patients.
After surgery, all patients felt significant alleviation of symptoms that were caused by lymphedema. The skin of the arm at surgery side remained soft in 10 patients at one year postoperatively. On evaluation of results of arm measurements, few patients could not follow the regular check-up schedule for visit due to inconvenience of the long distance transportation. The data were collected from the available patients.
Postoperative measurements showed significant decrease of circumferences of the arms on all levels at surgery side. The average account for circumference at the middle point of the forearm at surgery side was 32.55 ± 1.44 cm when compared to the circumference with 23.73 ± 1.54 cm of the contralateral arm before surgery. The average circumference at the same level of the arms at surgery side was decreased to 24.85 ± 1.89 cm and 26.84 ± 1.78 cm at 2 weeks and 3 months postoperative intervals, which were significantly different from the preoperative measurements (p<0.01). At postoperative 1 year and 3 years, the average circumferences at the middle forearm were 28.36 ± 1.90 cm and 29.30 ± 2.17 cm, which remained lower than that of preoperative measurement (p<0.01). The measurement results of average pre and postoperative circumferences of arms at surgery and contralateral sides are shown in Table 1.
The onsets of erysipelas were average 6.45 times per year in the patients before surgical treatment. In 10 patients, erysipelas did not recur within 1 year after surgery. Only one patient had erysipelas recurrence at 10 months after operation. Four patients had one erysipelas recurrence at the second year after surgery. Two patients had twice and three patients had one erysipelas recurrence at the third year after surgery. Pre- and postoperative onsets of erysipelas are shown in Table 2. Part of data on erysipelas recurrence was collected by telephone inquiry to the patients who could not follow the regular check-up schedule for visit.
Case Reports
Case 1
A 51-year-old woman suffered from chronic lymphedema of the left upper extremity for 9 years after she underwent the radical mastectomy and postoperative chemotherapy and radiation therapy for treatment of breast cancer. The lymphedema of arm was complicated with erysipelas, which occurred more frequently in the last 3 months prior to the surgery. In 2005, the patient underwent procedures of scar contracture release of left axilla, liposuction of left arm, lymph-fascia grafting and wound coverage with latissimus dorsal myocutaneous flap. The postoperative course was uneventful. The circumferences of the left upper extremity at different levels were significantly reduced. The maximum decrease in circumference at middle forearm was 6 cm. In three years postoperative follow-up, no recurrence of the left arm lymphedema was observed. No recurrence of erysipelas was observed. The skin of the left arm remained soft. Lymphoscintigraphy demonstrated the reflow of lymph drainage in left axillary site (Figure 1). The quality of the patient’s life was significantly improved.
Case 2
A 67-year-old woman admitted to our hospital with lymphedema and repeated erysipelas of the left upper extremity for 25 years. The patient had history of the radical mastectomy and postoperative chemotherapy and radiation therapy for treatment of breast cancer. We performed scar contracture releasement, liposuction, lymph-fascia grafting and the latissmus dorsal myocutaneous flap on the patient in 2004. The flap survived completely and wound healed uneventful after surgery. Measurements of circumferences of the left upper extremity showed significant improvement at different levels. No recurrence of erysipelas was observed and the skin of the left arm remained soft in three years follow-up (Figure 2).
Discussion
The principles for the surgical treatment of extremity lymphedema include removing the scar contracture, reducing the lymph reflow burden, and, most importantly, establishing the physiologic lymph drainage pathway. Although many surgical techniques, including excision and skin graft, staged excision, liposuction, microanastomosis between lymphatic and venous system, and lymph node transplantation,1-17 have been reported for treatment of the extremity lymphedema, none of those procedures have been demonstrated a reliable resolution for the problems.
Slavin et al. investigated the lymphatic function following free-tissue transfer in 10 patients. 18 Spontaneous anastomosis of lymphatics was found in the free transferred flaps by the radiocolloid lymphoscintigraphy with technetium-99m-antimony trisulfide colloid as early as 13 days postoperatively. Use of pedicle flaps as the lymphatic bridges for extremity lymphedema has been reported in last two decades. Chitale et al. reported tensor fascia lata musculocutaneous flap in the treatment of lymphedema of the lower extremity and external genitalia. 23 A consistent reduction in the size and edema of the affected areas was noted. Halperin et al. reported surgical management of scrotal lymphedema using local flaps in two patients.24 Both patients were satisfied with their results and had quality of life improved. Benoit et al. also introduced prevention of lymphedema with an omentum flap after ilioinguinal lymph node dissection.25
For treatment of the upper extremity lymphedema after mastectomy with flaps, there were only few reports on small series of patients. The omentum flap was reported for treatment of the upper extremity lymphedema in a patient after a breast cancer resection.26 Classen et al. reported a case of the free muscle flap transfer as a lymphatic bridge for upper extremity obstructive lymphedema.27 Kambayashi et al. also reported treatment of severe postmastectomy lymphedema of the upper extremity were with myocutaneous latissimus dorsi muscle flaps in two patients and achieved satisfactory results for control of edema.22 Previously we tried to use the lateral thoracic skin flap and latissimus dorsi musculocutaneous flap transplantations for treatment of the postmastectomy lymphedema in upper extremity in ten patients.21 Clinical observation showed that lymphedema could be ameliorated. However, the long-term results were inconsistent, which may be attributed to insufficiency of the lymphatic transport capacity of the flap for lymphatic drainage of the whole extremity.
Clinical evidences of no lymphedema have suggested that lymphatic vessels have ability to regenerate after extremity replantation surgery.19 In an experimental study of rabbit ear replantation, Anderson et al. observed that the edema began to subside at 14 postoperative days in the model of ear replantation with repairs of one artery and two veins.20 Lymphatic function was found restored in a lymphoscintigraphy study 21 days after surgery. These findings provide us the hypothesis for use of the lymph-rich fascia graft to provide extra bridge for lymph drainage in this obstructive disease. In this series of patients, we used the latissmus myocutaneous flap transfer and lymph-fascia grafting for treatment of severe post-mastectomy arm lymphedema. The transplanted lymph-fascia graft was inset to across the dissected axillary area and connect the arm to the supra-clavicle area as an extra lymphatic drainage pathway.
Reducing the lymph reflow burden is also one of important parts of the surgical treatment of lymphedema. Liposuction that removes the hypertrophied adipose tissue and accumulated lymph fluid has been proved an effective method for immediate reduction of lymph reflow burden.6-17 Liposuction can also decrease wound disruption and infection tendency caused by significant ooze of the lymph fluid after release of scar contracture and psychologically improve the quality of patient’s social life. We used liposuction to remove the hypertrophied adipose tissue in this series of patients, followed by myocutaneous flap and lymph-fascia grafting to establish the lymph drainage. The results have shown that this surgical strategy can significantly ameliorate the lymphedema and prevent its reoccurrence, and control of onsets of erysipelas.
Since the great sapheneous vein along with the surrounding lymph vessels rich fascia was transferred as a free lymph-rich fascia graft, the survival of this complex graft was concerned. Dissection of a thin graft was the major requirement in the graft harvest. In this series we did not perform vascular anastomosis of the great sapheneous vein in the wound after release of scar contracture. We believed that viability of the thin graft could be maintained when the graft was covered by a myocutaneous flap with good blood supply. The donor site morbidity was the other concern for the procedure of harvest of the great sapheneous vein and the surrounding fascia, but there was no chronic lymphedema found in the donor leg in all of patients.
Conclusions
In this report, we present our experience on treatment of the upper limb lymphedema with combined latissimus dorsal myocutaneous flap, liposuction and lymph-fascia grafting in a series of patients. The preliminary results were promising. This surgical strategy was indicated for the chronic upper extremity lymphedema with severe axillary scar contracture. The results suggested that both the transplanted lymph-fascia graft and myocutaneous flap might contribute establishment of the lymph drainage pathway. Long-term results will be evaluated in the patients. Further experimental studies are also planned for investigation of the role of lymph-fascia graft in treatment of lymphedema.
References
1. O’Brien BM, Mellow CG, Khazanchi RK, DvirE,Kumar V,PedersonWC. Long-term results after microlymphaticvenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85:562-572.
2. Campisi C, Davini D, Bellini C, Taddel G, Villa G, Fulcheri E, Zilli A, Rin ED, Eretta C, Boccardo F. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery 2006; 26:65-69.
3. Campisi C, Eretta C, Pertile D, Rin ED, Campisi C, Maccio A, Campisi M, Accogli S, Bellini C, Bonioli E, Boccardo F. Lymphatic microsurgery for the treatment of peripheral lymphedema: long-term outcome and future perspectives. Microsurgery 2007; 27:333-338.
4. Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: long-term results following lymph node transplantation. Ann Surg 2006; 243:313-315.
5. Miller TA, Wyatt LE, Rudkin GH. Staged skin and subcutaneous excision for lymphedema: a favorable report of long term results. Plast Reconstr Surg 1998; 102: 1486-1498.
6. Qi FZ, Gu JY, Zhang XJ, Shi YD, Wu KN. Liposuction in the treatment of limb lymphedema. Chin J Aesthet Plast Surg 2001; 12: 16-18.
7. Qi FZ, Gu JY, Shi YD, Zhang XJ, Wu KN. Preliminary report of Liposuction in the treatment of limb lymphedema: 46 cases. J Shanghai Med Univ 2000; 27: 138-140.
8. Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 1998; 102: 1058-1067.
9. Brorson H, Svensson H. Complete reduction of lymphedema of the arm by liposuction after breast cancer. Scand J Plast Reconstr Surg 1997; 31: 137-143.
10. Greene AK, Slavin SA, Borud L. Treatment of lower extremity lymphedema with suction-assisted lipectomy. Plast Reconstr Surg 2006; 118: 118e-121e.
11. Hoffmann JN, Fertmann JP, Baumeister RG, Putz R, Frick A. Tumescent and dry liposuction of lower extremities: Differences in lymph vessel injury. Plast Reconstr Surg 2004; 113: 718-724.
12. Frick A, Hoffmann JN, Baumeister RG, Putz, R. Liposuction technique and lymphatic lesions in lower legs: Anatomic study to reduce risks. Plast Reconstr Surg 1999; 103: 1868-1873.
13. Brorson H. Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta Oncol 2000; 39: 407-420.
14. Cao WG, Li SL, Zhou JG, Cheng KX, Liu NF, Zhang DS. Treatment of primary lower limb lymphedema with ultrasonic assisted liposuction. Chin J Plast Surg 2006; 22: 290-291.
15. Brorson H, Ohlin K, langstrom G, Wiklund I, Svensson H. Quality of life following liposuction and conservative treatment of arm lymphedema. Lymphol 2006; 39: 8-25.
16. O’Brien BM, Khazanchi RK, Kumar PA, Dvir E, Pederson WC. Liposuction in the treatment of lymphedema: a preliminary report. Br J Plast Surg 1989; 42: 530-533.
17. Sando WC, Nahai F. Suction lipectomy in the management of limb lymphedema. Clin Plast Surg 1989; 16: 369-373.
18. Slavin SA,Upton J, Kaplan WD,Van den Abbeele AD. An investigation of lymphatic function following free-tissue transfer.. Plast Reconstr Surg 1997; 99:730-741.
19. Smith AR, van Alphen WA, van der Pompe WB. Lymphatic drainage in patients after replantation of extremities. Plast Reconstr Surg 1987; 79:163-170.
20. Anderson DK, Zarem HA. The lymphatics in experimental flaps. Plast Reconstr Surg 1977; 59:264-268.
21. Shi YD, Qi FZ, Zhang XJ, Gu JY, Wu KN. Flap transplantation combined with liposuction to treat upper limb lymphedema after mastectomy. Zhonghua Zheng Xing Wai Ke Za Zhi 2003;19:430-432.
22. Kambayashi J, Ohshiro T, Mori T. Appraisal of myocutaneous flapping for treatment of postmastectomy lymphedema. Case report. Acta Chir Scand 1990;156:175-7.
23. Chitale VR. Role of tensor fascia lata musculocutaneous flap in lymphedema of the lower extremity and external genitalia. Ann Plast Surg 1989; 23:297-304.
24. Halperin TJ, Slavin SA, Olumi AF, Borud LJ. Surgical management of scrotal lymphedema using local flaps. Ann Plast Surg 2007; 59:67-72.
25. Benoit L, Boichot C, Cheynel N, Arnould L, Chauffert B, Cuisenier J, Fraisse J. Preventing lymphedema and morbidity with an omentum flap after ilioinguinal lymph node dissection. Ann Surg Oncol 2005; 12:793-799.
26. Nakajima E, Nakajima R, Tsukamoto S, Koide Y, Yarita T, Kato H. Omental transposition for lymphedema after a breast cancer resection: report of a case. Surg Today 2006; 36:175-179.
27. Classen DA, Irvine L. Free muscle flap transfer as a lymphatic bridge for upper extremity lymphedema. J Reconstr Microsurg 2005; 21:93-99.
Legends
Figure 1: A: The left arm lymphedema before surgery. B: The scar contracture at the axillary area. C: The design of the flap. D: The transferred lymph-fascia tissue. E: Three years after operation. F: Lymphoscintigraphy demonstrated the reflow of lymph drainage in left axillary site after surgery.
F igure 2: A 67-year-old woman had left upper limb lymphedema after radical mastectomy and irradiation therapy. A: The left arm lymphedema before operation.B: The lymphtic-bearing fascia graft. C: Myocutaneous flap was transferred. D: Three years after the operation. E: The close appearance of the left arm 3 years after operation.
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