Anne G. Warren

Lymphedema - A comprehensive review

Background:Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective. Objective:To provide a systematic approach to evaluating and managing patients with lymphedema. Methods:We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer–associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed. Results:In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms. Conclusions:The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

The use of alloplastic materials in rhinoplasty surgery: a meta-analysis.

Background: Conventional wisdom regarding the use of alloplastic materials in rhinoplastic surgery would advise against their use because of safety and aesthetic concerns. However, autogenous tissue harvest is not without associated morbidity and may be inadequate or insufficient in some clinical situations. Prior studies examining this issue have not provided definitive recommendations regarding implant selection, ideal locations in which to use specific implants, and necessary follow-up. Methods: First, the authors systematically reviewed the available literature on alloplastic implant use in rhinoplastic surgery by searching the MEDLINE database (from 1966 through September of 2005). Bibliographies from retrieved articles were searched for additional references. All data were independently extracted by two coauthors. Second, the authors performed a meta-analysis of the three most commonly used implant types. Results: Although a wide variety of alloplastic materials have been used historically and are still currently available, the most commonly used materials are silicone, expanded polytetrafluoroethylene (Gore-Tex), and porous high-density polyethylene (Medpor). In our meta-analysis, the removal rate for both Gore-Tex and Medpor implants was 3.1 percent, whereas the removal rate for silicone implants was significantly higher at 6.5 percent. Conclusions: Alloplastic implants in rhinoplastic surgery have acceptable complication rates and can be used when autogenous materials are unavailable or insufficient. Outcomes with Medpor or Gore-Tex implants may be slightly better than those with silicone. Improved reporting of implant failures and follow-up times in future studies are needed to better define specific guidelines for the use of these materials.

The use of bioimpedance analysis to evaluate lymphedema.

Background:Lymphedema, a chronic disfiguring condition resulting from lymphatic dysfunction or disruption, can be difficult to accurately diagnose and manage. Of particular challenge is identifying the presence of clinically significant limb swelling through simple and noninvasive methods. Many historical and currently used techniques for documenting differences in limb volume, including volume displacement and circumferential measurements, have proven difficult and unreliable. Bioimpedance spectroscopy analysis, a technology that uses resistance to electrical current in comparing the composition of fluid compartments within the body, has been considered as a cost-effective and reproducible alternative for evaluating patients with suspected lymphedema. Patients and Methods:All patients were recruited through the Beth Israel Deaconess Medical Center Lymphedema Clinic. A total of 15 patients (mean age: 55.2 years) with upper-extremity or lower-extremity lymphedema as documented by lymphoscintigraphy underwent bioimpedance spectroscopy analysis using an Impedimed SFB7 device. Seven healthy medical students and surgical residents (mean age: 26.9 years) were selected to serve as normal controls. All study participants underwent analysis of both limbs, which allowed participants to act as their own controls. The multifrequency bioimpedance device documented impedance values for each limb, with lower values correlating with higher levels of accumulated protein-rich edematous fluid. Results:The average ratio of impedance to current flow of the affected limb to the unaffected limb in lymphedema patients was 0.9 (range: 0.67 to 1.01). In the control group, the average impedance ratio of the participants dominant limb to their nondominant limb was 0.99 (range: 0.95 to 1.02) (P = 0.01). Conclusions:Bioimpedance spectroscopy can be used as a reliable and accurate tool for documenting the presence of lymphedema in patients with either upper- or lower-extremity swelling. Measurement with the device is quick and simple and results are reproducible among patients. Given significant limitations with other methods of evaluating lymphedema, the use of bioimpedance analysis may aid in the diagnosis of lymphedema and allow for tracking patients over time as they proceed with treatment of their disease.

Modified vertical abdominoplasty in the massive weight loss patient.

Background: Patients with massive weight loss following bariatric surgery are now presenting in large numbers for body contouring. To achieve optimum cosmetic results in these patients, a comprehensive circumferential approach is usually required that includes the lateral thighs and buttocks. For a number of reasons, many patients are not candidates for these comprehensive procedures. Some patients view the circumferential procedures as too extensive or aggressive. Others have large hernias or other medical conditions that necessitate a more limited approach. Still others do not have sufficient resources to treat multiple areas. Methods: A 2-year review of patients presenting with a chief complaint of anterior lower abdominal tissue excess as a consequence of massive weight loss following bariatric procedures was conducted. In 64 cases, patients opted for anterior-only treatment of the lower trunk. Results: Average operative time in patients undergoing modified abdominoplasty alone was 2.5 hours. The mean mass of the excised panniculectomy specimens was 3.8 kg (range, 1.1 to 10.0 kg). The most common complication was wound dehiscence at the T-junction (27 percent), which was treated successfully with local wound care in all cases and did not require reoperation to achieve wound closure. There were no known thromboembolic events. Conclusions: Not all massive weight loss patients are suitable candidates for comprehensive circumferential body contouring procedures, and many patients desire a limited anterior approach to the frontal abdomen. The modified vertical abdominoplasty should be considered as an option in these patients.

Evaluation and management of the fat leg syndrome.

Learning Objectives: After studying this article, the participant should be able to: 1. Discuss the initial evaluation of a patient presenting with lower extremity enlargement. 2. Distinguish underlying medical conditions causing lower extremity enlargement, including lymphedema and lipedema. 3. Discuss appropriate management and treatment for patients presenting with these conditions. Background: Given the epidemic of obesity in the United States, many patients will consult the plastic surgeon with complaints of lower extremity enlargement secondary to “fat legs.” In addition to cosmetic disfigurement, some patients may suffer from underlying medical conditions that are responsible for their symptoms. Knowledge of these other causes, including lymphedema and a disorder of abnormal fat deposition known as lipedema, ensures appropriate management and/or surgical treatment for affected patients. Methods: Initial evaluation for lower extremity enlargement should include a discussion of pertinent medical history and a focused physical examination for findings that might indicate a pathologic underlying cause. When indicated, patients should undergo additional testing, including radiologic studies, to confirm their diagnoses. Results: For those patients found to have lymphatic dysfunction, conservative management, such as massage therapy, use of compression garments, and limb elevation, should be initially recommended. Excisional or suction-assisted lipectomy may be considered in patients who fail conservative therapy. More extensive consultation with the plastic surgeon is recommended for patients seeking aesthetic improvement in contour and shape of large legs without a specified underlying abnormality. Conclusions: Patients with lower extremity enlargement may present to the plastic surgeon unsure of the specific cause of their deformity. A broad differential diagnosis exists for their presentation, which can be narrowed by using the common features and unique manifestations of the conditions.

Scar lymphedema: fact or fiction?

Background:Few concepts are as fundamental to plastic surgery as scarring, yet swelling within a scar and its adjacent tissues is a common observation which is not well understood. Mechanical forces, scar contracture, fibrosis, and lymph stasis have been considered as possible explanations for these edematous-appearing areas, but conclusive evidence of a cause of swelling has not been established. The purpose of this study was to evaluate the possible role of microlymphatic stasis or disruption as a causal factor. Patients and Methods:Eleven patients (mean age: 43; range: 15 to 70) with localized swelling in conjunction with linear or curvilinear scars were evaluated, 9 with facial scars and 2 with scars of the chest wall and abdomen. Swelling within the scar had been present for an average of 4.5 years (range: 9 months to 13 years). Two patients had undergone previous Z-plasty revisions to the limbs of their curvilinear scars. Radiocolloid lymphoscintigraphy with technetium-99m Sb2S3 was performed on all patients by single or multiple injection technique into the site of the scar corresponding to local edema. Results:Following injection, rapid egress of radiotracer was visualized along lymphatic pathways posterior to the scar, with continuation to locoregional nodes in all patients with U-shaped “trapdoor” or linear scar configuration. However, in 8 cases there was no evidence of lymphatic drainage traversing or bridging the scar. In 2 patients with multiple prior Z-plasty revisions to the limbs of curvilinear scars, no visualization of lymph channels across the Z-plasty flaps was apparent. In total, 8 patients were diagnosed with lymphedema of the area adjacent to or enclosed within the scar. Conclusions:These findings suggest that undrained lymphatic fluid contributes to the pathogenesis of the raised and swollen tissues seen abutting a U-shaped scar. Furthermore, as lymphatic pathways do not reestablish themselves across scars, attempts at improving lymphatic flow with Z-plasty revisions may not succeed in patients with clinical trapdoor scar deformities. Determination of scar lymphedema can assist in the selection of proper management for patients seeking scar revision.

Learning from a lymphedema clinic: an algorithm for the management of localized swelling.

Background: Lymphedema is a chronic disease causing significant morbidity for affected patients. It can be difficult to diagnose, and patients are often frustrated by multiple referrals and inadequate therapies. Centralized, comprehensive care for the patient presenting with lymphedema or other causes of localized swelling allows for appropriate evaluation and provides improved management and treatment. Methods: A 4-year review of the first 100 patients seen at the Beth Israel Deaconess Medical Center Lymphedema Clinic was performed. On the basis of the clinical experience from these patients, an algorithm for diagnosing and managing patients with localized swelling was developed. Results: The mean age of the patients was 50 years, and 81 percent of the patients were women. On average, patients had experienced their symptoms for 11.6 years (range, 3 months to 60 years). Lymphoscintigraphy was performed on 43 patients, 81 percent of whom showed lymphatic obstruction or dysfunction. In total, 75 percent of patients were diagnosed with lymphedema based on clinical presentation or additional testing. Fourteen of these patients underwent subsequent excisional procedures, whereas the rest were managed conservatively with compression garments. Conclusions: Patients presenting with swollen extremities can frequently be diagnosed through history and physical examination alone, but many patients require more extensive diagnostic workup. An algorithm for the management of these patients can facilitate evaluation and treatment.

Breast reconstruction in a changing breast cancer treatment paradigm.

Current trends in the treatment of breast cancer reveal a progressively higher value being placed on the conservation of breast tissue. In the shift from the radical mastectomies of Halsted to breast-conserving therapies, there has been a greater realization of the possibility and the benefits of providing less invasive procedures with decreased tissue volume resections as procedures are increasingly tailored to specific tumor characteristics. This move toward smaller procedures and more individualized therapies achieves multiple advances in improving care and outcomes for women undergoing breast cancer treatment. The goal of recent developments in breast conservation therapy, including sentinel lymph node biopsy and partial breast irradiation techniques, is to decrease morbidity and complications for women. In addition to improving functional results for women, these new advances allow breast surgeons and plastic surgeons to truly maximize aesthetic and reconstructive outcomes. The use of bilateral reduction mammaplasty as a strategy for avoiding breast contour defects after large-volume partial mastectomy has shown excellent results in optimizing breast symmetry and appearance. When mastectomy is indicated, breast surgeons are preserving an increasing amount of skin envelope through skin-sparing and nipple-sparing mastectomy techniques, providing plastic surgeons with an improved aesthetic pocket in which to place implants or autologous tissue flaps and a virtually intact nipple-areola complex that requires little, if any, further reconstruction. Refinement of the deep inferior epigastric perforator (DIEP) flap and other perforator flaps has continued to improve outcomes after autologous tissue reconstructions. In this article, the authors review the recent development of new tools, techniques, and strategies for the management of breast cancer. The paradigm shift shaping the surgical treatment of breast cancer makes the current options and environment in the field of breast reconstruction ever evolving and increasingly rewarding.