Graham S. Schwarz

A Review of Treatment for Breast Cancer-Related Lymphedema: Paradigms for Clinical Practice

Objectives: Breast cancer–related lymphedema (BCRL) represents a major complication of breast cancer treatment, impacting the quality of life for breast cancer survivors that develop it. The purpose of this review is to evaluate the literature surrounding BCRL treatment modalities to guide clinicians regarding risk-stratified treatment options. Methods: A review of studies over a 10-year period (January 2006 to February 2016) was performed. Noninvasive strategies evaluated included compression therapy, manual lymphatic drainage, and complex decongestive therapy (CDT). Invasive modalities evaluated included liposuction and lymphatic bypass/lymph node transfer (LNT). Our search yielded 149 initial results with 45 studies included. Results: A number of prospective studies have found that CDT is associated with volume reduction in the affected limb as well as improved quality of life, particularly in patients with early stage BCRL. With regards to invasive treatment options, data support that lymphatic bypass and LNT are associated with symptomatic and physiologic improvements, particularly in patients with more advanced BCRL. In addition, a small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe BCRL. Conclusions: CDT is an effective treatment modality for early stage BCRL. For more advanced BCRL, LNT has demonstrated efficacy. Further study is required with respect to comparing BCRL treatment modalities.

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA; formerly Wegeners granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten‐year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1‐year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Vascularized axillary lymph node transfer: A novel model in the rat.

Vascularized lymph node transfer (VLNT) is a promising microvascular free flap technique for the surgical treatment of lymphedema. To date, few experimental animal models for VLNT have been described and the viability of lymph nodes after the transfer tested. We aimed to evaluate the feasibility of axillary VLNT in the rat. Lymph node containing flaps were harvested from the axillary region in 10 Lewis rats based on the axillary vessels. Flaps were transferred to the ipsilateral groin and end‐to‐side microanastomosis was performed to the femoral vessels using 10‐0 sutures. Indocyanine green (ICG) angiography was used to confirm flap perfusion. On postoperative day 7, flaps were elevated to assess their structure and vessel patency. Hematoxylin and eosin staining was used to confirm the presence and survival of lymph nodes. All animals tolerated the procedure well. Immediate post‐procedure ICG angiography confirmed flap perfusion. No signs of ischemia or necrosis were observed in donor extremities. At postoperative day 7, all flaps remained viable with patent vascular pedicles. Gross examination and histology confirmed the presence of 3.6 ± 0.5 lymph nodes in each flap without any signs of necrosis. This study showed that the transfer of axillary lymph nodes based on the axillary vessels is feasible. The flap can be used without the need for donor animals and it contains a consistent number of lymph nodes. This reliable VLNT can be further utilized in studies involving lymphedema, transplantation, and induction of immunologic tolerance.

Examining reduction mammaplasty in Hispanic and African American populations: A changing landscape in American plastic surgery

As 21st century physicians, we are witnessing a change in the American landscape with an increased proportion of non-Caucasian patients, particularly Black and Hispanic individuals. The Census Bureau predicts that by 2050, the American population will be one quarter Hispanic, yet the plastic surgical literature rarely addresses this growing population. We aimed to determine if specific factors in this population influence preoperative planning and counseling, guide intra-operative decisions, or affect surgical outcomes. Following approval by the Institutional Review Board at Columbia University Medical Center, the authors performed a retrospective chart review of consecutive breast reduction cases completed at a single center between 2003 and 2007. Patient charts were evaluated for demographic background, pre-operative complaints and counseling, operative techniques, pathology specimens, and postoperative complications and outcomes. The method of breast reduction chosen was determined by projected nipple movement, estimated reduction weight, and patient/surgeon preference (JA, JW, CR). Post-operatively, patients had scheduled office appointments at 1-2 weeks, 6 wks, at 6 months, and then yearly. 161 patients underwent reduction mammaplasty. 116 (72%) of the patients classified themselves as nonCaucasian. (Table 1) All patients were followed for at least one year. The mean age was 35 years for nonCaucasians and 38 years for Caucasians (p Z ns). NonCaucasian women had a significantly higher body-massindex (BMI Z kg/m) and body-surface-area (BSAZ[Height (cm) Weight (kg)]/3600) than their Caucasian counterparts. Non-Caucasian women were more likely to have a history of smoking and have larger brassiere band sizes. Non-Caucasian patients were more likely to complain of

Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: A meta-analysis of the literature

Arteriovenous (AV) loops can be utilized in a single‐ or two‐stage approach in free flap reconstruction when proper vessels are not available. However, there exists no consensus on which method leads to superior microsurgical and patient outcomes. The purpose of this article was to review single‐ versus two‐stage AV loops utilized in free flap reconstruction with a focus on complications and overall outcomes.

Quantity of Lymph Nodes in the Vascularized Lymph Node Transfer Influences Its Lymphaticovenous Drainage

Background The purpose of this study was to: (1) evaluate the mechanism of lymph drainage through a vascularized lymph node (VLN) flap, and (2) investigate if the number of VLNs impacts lymph transit time through the flap. Methods Twenty‐seven axillary VLN flaps were elevated in 14 Sprague‐Dawley rats and divided into three groups (n = 9 each) based on the number of lymph nodes present: group 1 (0‐VLNs), group 2 (2‐VLNs), and group 3 (4‐VLNs). Indocyanine green (n = 8/group) and Alexa680‐albumin (n = 1/group) were injected into the edge of flaps and the latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through VLNs. Results Fluorescence was detected in the axillary vein after 229s [47‐476], 79s [15‐289], and 56s [16‐110] in group 1, 2, and 3, respectively (p < 0.01). There was a negative correlation between the number of VLNs in the flap and the latency period (r = −0.59; p < 0.05). Median flap weights were comparable in group 1, 2, and 3 (258 mg [196‐349], 294 mg [212‐407], 315 mg [204‐386], respectively; p = 0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit through VLNs. Conclusion Lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism appears to be the diffusion of fluid into the venous system via intratissue lymphaticovenous connections created during flap elevation. Increasing the number of lymph nodes in the flap is associated with a more rapid transit of fluid.

Comparison of Liposomal Bupivacaine for Pain Management after Immediate and Delayed Deep Inferior Epigastric Perforator Free Flap Reconstruction

Patient analgesia can be addressed pre, intra and post-operatively. The utilization of local anesthetics administered intra-operatively is limited by the medication’s short duration of action. However, an intraoperative transversus abdominis plane (TAP) block can be utilized to anesthetize the T6-L1 intercostal nerves that supply the anterior abdominal wall. This provides analgesia to the abdominal wall, which has been identified as the largest source of post-operative pain following abdominally-based autologous tissue breast reconstruction.

Triple Mapping to Optimize Axillary Management in Breast Cancer Patients After Neoadjuvant Therapy

Sentinel lymph node (SLN) biopsy is an option after neoadjuvant chemotherapy in patients who are clinically node negative. False negative rates decrease with dual mapping and identification of more than three SLNs. Patients with positive SLNs require axillary lymph node dissection (ALND). Axillary reverse mapping (ARM) with lymphovenous bypass (LVB) is a lymphedema prevention technique that can be performed in patients who require ALND. It entails injection of isosulfan blue into the proximal extremity to identify lymph nodes and lymphatics draining the arm. LVB performed at the initial surgery reestablishes the drainage of cut lymphatics, potentially decreasing the risk of subsequent lymphedema. We describe a triple mapping technique that can be used to perform both SLN biopsy and subsequent ALND.

Oncoplastic Surgery in Breast Cancer: Don’t Forget the Boost!

A growing focus on cosmetic outcomes for women undergoing breast-conserving therapy has emerged, spurring the development of oncoplastic/partial breast reconstruction surgical techniques. Oncoplastic techniques can be offered to a large number of patients and include a variety of procedures. Local breast tissue rearrangements such as glandular advancement or rotation flaps can be employed for smaller defects, whereas, mastopexy and reduction mammoplasty may be offered for larger resections and in patients with larger-volume breasts. The goals of these techniques are multifold and include restoration of an aesthetic breast contour and optimization of breast symmetry, while enabling the surgeon to obtain generous margins during oncologic resection. Furthermore, patients with macromastia or significant ptosis undergoing radiotherapy may benefit from both reduced toxicity and improved function through relief of symptomatic macromastia. Taken together, these benefits translate into improvements in breast-related quality of life in women with breast cancer. However, one of the challenges associated with the increased use of oncoplastic techniques is incorporating the tumor bed boost that often accompanies whole-breast irradiation (WBI) following breast-conserving surgery. As such, the questions that have emerged include (1) what is the role of tumor bed boost following breast-conserving surgery, and (2) how can oncoplastic surgery be integrated into a paradigm that includes tumor bed boosts? WHY IS A TUMOR BED BOOST IMPORTANT IN THE MANAGEMENT OF BREAST CANCER?

Abstract 58. Single-Stage versus Two-Stage Arteriovenous Loop Microsurgical Reconstruction: An Evidence Based Review of the Literature and Analysis of Institutional Experience

RESULTS: The decision tree shows the associated QALYs, costs and probabilities used to calculate the ICUR of