Delayed Breast Reconstruction on Patients With Upper Extremity Lymphedema A Systematic Review of the Literature and Pooled Analysis

Charalampos Siotos, Aladdin H. Hassanein, Ricardo J. Bello, Mohamad E. Sebai , Stella M. Seal, MLS, Michele A. Manahan, Damon S. Cooney, Carisa M. Cooney, and Gedge D. Rosson. Annals of Plastic Surgery 2018

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Delayed Breast Reconstruction on Patients With Upper Extremity Lymphedema

A Systematic Review of the Literature and Pooled Analysis

Charalampos Siotos, Aladdin H. Hassanein, Ricardo J. Bello,  Mohamad E. Sebai , Stella M. Seal, MLS, Michele A. Manahan, Damon S. Cooney,  Carisa M. Cooney, and Gedge D. Rosson. Annals of Plastic Surgery 2018

Background: Breast cancer–related lymphedema (BCRL) is a debilitating condition with morbidity, hindered quality of life, and increased health-related costs. Experimental studies support the use of musculocutaneous flaps for managing animal models with lymphedema. Although vascularised lymph node transfer (VLNT) and lymphovenous anastomosis are used to surgically treat patients with lymphedema, it is not known whether musculocutaneous or adipocutaneous flaps (eg, delayed autologous breast reconstruction) are effective for treating refractory upper extremity BCRL. We conducted a systematic review and pooled analysis to assess the impact of delayed breast reconstruction on developed BCRL.

Methods: Following PRISMA guidelines, we systematically searched PubMed, Scopus, EMBASE, and Google Scholar databases for relevant studies published through November 11, 2016. We screened 934 unique articles. Of these, we conducted full-text and reference screening on 37 articles. We then performed a pooled and sensitivity analysis using random effects.

Results: Eight studies met our inclusion criteria. One study was a case report; 7 studies were case series with sample sizes ranging from 3 to 38 patients. According to our pooled analysis 58% of patients reported improvement after breast reconstruction with or without VLNT. Sensitivity analysis revealed that 84% (95% confidence interval, 0.74–0.95) of patients who underwent breast reconstruction and VLNT reported improvement, whereas only 22% (95% confidence interval, 0.12–0.32) of those who had breast reconstruction alone reported improvement.

Conclusions: Our review summarises the current evidence regarding the effect of delayed breast reconstruction on established lymphedema. The VLNT component of the autologous breast reconstruction procedures may be the largest contributing factor leading to lymphedema improvement.

Main findings

  • A systematic search of the literature for articles published through November 11, 2016.
  • Studies that included qualitative synthesis = 8 and quantitative synthesis = 5
  • The proportion of patients who report improvement of their BCRL after delayed autologous breast reconstruction is statistically significantly higher than the proportion of those patients who report deterioration or unchanged status of BCRL. However, the benefit was more prominent when breast reconstruction was conducted along with lymph node transfer. Indeed, the effect was 4-fold greater when VLNT was performed.
  • All studies agree that delayed breast reconstruction probably does not cause worsening of the lymphedema.
  • The present study is not without limitations. The small number of included studies and the fact that most of the studies were case series with low level of evidence limit our ability to draw definitive conclusions. In addition, they have noticed discrepancies concerning the methods of diagnosis and assessment of lymphedema across the individual studies, which may introduce heterogeneity into their analysis.