Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer
Corinne Becker1, Lionel Arrivé2, Giuseppe Mangiameli1, Ciprian Pricopi1, Fanomezantsoa Randrianambinina1, and Francoise Le Pimpec-Barthes1,3. SICOT-J 2018, 4, 53
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Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer
Corinne Becker1, Lionel Arrivé2, Giuseppe Mangiameli1, Ciprian Pricopi1, Fanomezantsoa Randrianambinina1, and Francoise Le Pimpec-Barthes1,3. SICOT-J 2018, 4, 53
Post-traumatic localized hand lymphedema is a rare situation and its diagnosis may be difficult, causing lack of care leading to failure of care. Our case study is of two young women with massive post-traumatic hand lymphedema who were treated for algodystrophy for 2 years, and whose bandages and physiotherapy were unsuccessful. Major social and psychological consequences were observed due to difficulty with diagnosis and management over several years. Noncontrast magnetic resonance lymphography revealed complete lymphatic vessel blockage in the hand and wrist. A vascularized lymph node flap harvested at the groin level was transferred to the elbow level 1 month after local dermolipectomy. These procedures resulted in the restoration of lymphatic flow. Both patients were definitely cured, and they returned to normal life within 6 months after surgery. Lymph node flap transfer associated with dermolipectomy may cure massive localized lymphedema in selected cases.
Main findings
Case 1
- 21 year old woman had a bicycle accident that resulted in severe trauma of her right hand.
- The noncontrast magnetic resonance lymphography (NCMRL) demonstrated local lymph flow (LF) blockage at the wrist. It was associated with lymphatic malformations of the entire forearm, justifying a surgical procedure. An extrafascial dermolipectomy was first performed (Figure 2a). Local advanced flaps were performed to close the hand. This first step was essential to remove all fibrous and nonfunctional tissue obstructing lymphatic circulation. This allowed for the removal of the strangulation at the wrist. One month following dermolipectomy, the time necessary for the hand to heal later, a free flap containing some lymph nodes (VLNFT) was performed. The autologous donor flap harvested at groin level was transferred to elbow level. It was supplied by superficial circumflex iliac artery and contained lymph nodes, lymphatic vessels, and fat. One arterial and one venous anastomosis were performed to connect flap vessels to perforate branches (artery and vein) around the elbow. Lymphatic vessels were kept intact, allowing the spontaneous anastomoses to appear, which are the signs of lymphatic growth. The postoperative course was uneventful with rapid functional recovery. At the 1-year follow-up, the hand was nearly normal and there is no lower limb lymphedema. The patient returned to the university and could play the piano and the guitar again.
Case 2
- A 26-year-old woman without former medical history had had a right-hand lymphedema for 4 years, which evolved quickly within a few weeks. The origin was apparently a burn of the hand. At that time, the hand weighed 6kg. The lymphedema was painful and required daily morphine intake.
- An obstruction of the LF at elbow level was confirmed. A two-stage surgical procedure was decided consisting of an extrafascial dermolipectomy of the hand, followed, 1 month later, by a VLNFT from the groin area to the elbow. The same surgical procedure as described in case 1 was performed. In the postoperative course, forearm compression by bandage was maintained. The hand quickly ameliorated and was functional after 6 months, allowing the patient to work again. The postoperative NCMRL showed new LVs at elbow level and normal LF.
