Journal of Plastic, Reconstructive & Aesthetic Surgery
Orthotopic transfer of vascularized groin lymph node flap in the treatment of breast cancer-related lymphedema: Clinical results, lymphoscintigraphy findings, and proposed mechanism
Introduction
Vascularized lymph node transfer (VLNT) is gaining popularity in the treatment of secondary limb lymphedema. Groin and mesentery were the main sources of lymphatic tissue in the earlier series.1, 2 With improvements in surgical technique, more donor sites have been described, which include the neck, axilla, and intra-abdominal donor site.3, 4, 5, 6, 7
Regarding the recipient site, flap placement can be either orthotopic at the axilla or heterotopic, i.e., at any sites distal to the axilla.
Different combinations of donor and recipient sites have been studied clinically for the treatment of breast cancer-related lymphedema (BCRL). However, researchers have not taken much effort to provide evidence of the VLNT mechanism in humans.
This is a series of 30 consecutive cases operated by a single microvascular plastic surgeon. A skinless vascularized groin lymph node (VGLN) flap was transferred to the axilla for the treatment of BCRL. Patient demographics, operation technique, and clinical results are described in the study. Lymphoscintigraphy findings are discussed in detail for elucidating the mechanism of VLNT.
Section snippets
Patients
Between August 2013 and June 2016, 30 consecutive patients with BCRL were included in this study. The mean age was 60 (range, 45 to 79) years. All 30 patients had axillary dissection. Twenty-seven patients received adjuvant radiotherapy and 28 received chemotherapy.
The mean duration of lymphedema was 6 years (range, 1 to 20 years). The International Society of Lymphology's staging system was adopted in this series.8 One patient had stage I lymphedema, 25 patients had stage II disease, and 4
Clinical results
At a mean follow-up of 22.11 ± 7.83 months (range, 12 - 34months), no patient developed increase in limb circumference, 9 (30%) patients had no limb circumference reduction, and 21 (70%) patients had limb circumference reduction.
For the 9 patients who had no improvement, 6 had ISL II edema and 3 had ISL late II edema. While for the 21 patients with improvement, 1 had ISL I edema, 19 had ISL II edema, and 1 had ISL late II edema. There was no significant difference in the mean duration of
Discussion
Different donor sites have been described in the literature, which include the submandibular region, supraclavicular fossa, axilla, groin, and intra-abdominal donor sites.2, 3, 4, 5, 6, 7 There is no evidence to support which donor site is more superior than others, as no comparative study has been conducted.
Each donor site has its own advantages and disadvantages, e.g., visible scar of the neck donor site, possibility of iatrogenic lymphedema from axillary and groin lymph node harvesting,
Conclusion
The effectiveness of VGLN flap transfer in the treatment of BRCL is supported by limb circumference reduction and improvements in lymphoscintigraphy parameters.
This is one of the few case series in the literature describing the lymphoscintigraphy findings after orthotopic VGLN flap transfer. The visualization of transplanted lymph node in lymphoscintigraphy suggests lymphangiogenesis in VLNT.
Conflicts of interest
None to declare.
Financial disclosures
None to declare.
Acknowledgments
The corresponding author (LHL) would like to thank Dr Corinne Becker for teaching the technique of orthotopic VGLN transfer. The remaining authors also thank Dr Jaume Masià for providing ideas in Discussion.
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Part of this manuscript was presented at the 9th Congress of World Society for Reconstructive Microsurgery. Seoul, South Korea, 2017.