Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients’ related outcomes. A retrospective comparative study

M. Marucciaa, R. Eliaa , ∗, P. Ciudadb, E. Nacchieroa, F. Nicolic, M. Vestitaa, H.C. Chenb, G. Giudicea. Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 000, 1–10

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Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients’ related outcomes. A retrospective comparative study

Marucciaa, R. Eliaa , ∗, P. Ciudadb, E. Nacchieroa, F. Nicolic, M. Vestitaa, H.C. Chenb, G. Giudicea. Journal of Plastic, Reconstructive & Aesthetic Surgery (2019) 000, 1–10

Introduction: Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient’s existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by post-mastectomy upper limb lymphedema. The idea.

Materials and methods: All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire.

Results: Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow- up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups ( p < 0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores ( p < 0.0001) in all domains at all follow-up appointments in Group A.

Conclusions: Patients with post-mastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients’ quality of life.

Main findings

  • The idea to perform a scar tissue release with autologous fat graft and vascularized lymph node transfer during the same surgical session to treat postmastectomy upper extremity lymphedema was based on the concept that the two procedures could act at different level.
  • They opted to perform the VLNT to a distal location instead of the lymph node-depleted area.
  • Second, the axillary scar in the affected arm was released, as the scar tissue may block the lymphatic flow. The scar release was achieved through autologous fat grafting.
  • They believe autologous fat grafts show the ability to regenerate the dermis and subcutaneous tissue and improve the dermal and dermohypodermic quality in scar areas through increases in the fat layer.
  • The authors believe the efficacy, even only in the short-term follow-up, in fastening the limb circumference reduction and improving patient-related surgical outcomes makes it reasonable to think that this approach could be useful for the treatment of postmastectomy upper limb lymphedema, adding only a little time and costs to the overall surgical procedure. The authors advocate further larger research to corroborate and expand the results of the study.