Thomas C. Lam

Liposuction for Advanced Lymphedema: A Multidisciplinary Approach for Complete Reduction of Arm and Leg Swelling

PurposeThis research describes and evaluates a liposuction surgery and multidisciplinary rehabilitation approach for advanced lymphedema of the upper and lower extremities.MethodsA prospective clinical study was conducted at an Advanced Lymphedema Assessment Clinic (ALAC) comprised of specialists in plastic surgery, rehabilitation, imaging, oncology, and allied health, at Macquarie University, Australia. Between May 2012 and 31 May 2014, a total of 104 patients attended the ALAC. Eligibility criteria for liposuction included (i) unilateral, non-pitting, International Society of Lymphology stage II/III lymphedema; (ii) limb volume difference greater than 25xa0%; and (iii) previously ineffective conservative therapies. Of 55 eligible patients, 21 underwent liposuction (15xa0arm, 6xa0leg) and had at least 3xa0months postsurgical follow-up (85.7xa0% cancer-related lymphedema). Liposuction was performed under general anesthesia using a published technique, and compression garments were applied intraoperatively and advised to be worn continuously thereafter. Limb volume differences, bioimpedance spectroscopy (L-Dex), and symptom and functional measurements (using the Patient-Specific Functional Scale) were taken presurgery and 4xa0weeks postsurgery, and then at 3, 6, 9, and 12xa0months postsurgery.ResultsMean presurgical limb volume difference was 45.1xa0% (arm 44.2xa0%; leg 47.3xa0%). This difference reduced to 3.8xa0% (arm 3.6xa0%; leg 4.3xa0%) by 6xa0months postsurgery, a mean percentage volume reduction of 89.6xa0% (arm 90.2xa0%; leg 88.2xa0%) [pxa0<xa00.001]. All patients had improved symptoms and function. Bioimpedance spectroscopy showed reduced but ongoing extracellular fluid, consistent with the underlying lymphatic pathology.ConclusionsLiposuction is a safe and effective option for carefully selected patients with advanced lymphedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.

Lipidomic Profiling of Adipose Tissue Reveals an Inflammatory Signature in Cancer-Related and Primary Lymphedema.

Cancer-related and primary lymphedema (LE) are associated with the production of adipose tissue (AT). Nothing is known, however, about the lipid-based molecules that comprise LE AT. We therefore analyzed lipid molecules in lipoaspirates and serum obtained from LE patients, and compared them to lipoaspirates from cosmetic surgery patients and healthy control cohort serum. LE patient serum analysis demonstrated that triglycerides, HDL- and LDL-cholesterol and lipid transport molecules remained within the normal range, with no alterations in individual fatty acids. The lipidomic analysis also identified 275 lipid-based molecules, including triacylglycerides, diacylglycerides, fatty acids and phospholipids in AT oil and fat. Although the majority of lipid molecules were present in a similar abundance in LE and non-LE samples, there were several small changes: increased C20:5-containing triacylglycerides, reduced C10:0 caprinic and C24:1 nervonic acids. LE AT oil also contained a signature of increased cyclopropane-type fatty acids and inflammatory mediators arachidonic acid and ceramides. Interestingly C20:5 and C22:6 omega-3-type lipids are increased in LE AT, correlating with LE years. Hence, LE AT has a normal lipid profile containing a signature of inflammation and omega-3-lipids. It remains unclear, however, whether these differences reflect a small-scale global metabolic disturbance or effects within localised inflammatory foci.

Can an Immediate 2-stage Breast Reconstruction Be Performed After Previous Conservative Surgery and Radiotherapy?

Background: Prosthetic breast reconstruction is generally considered contraindicated after previous breast irradiation. As a result, patients undergoing a salvage mastectomy for recurrent breast cancer or “risk-reducing” mastectomies after previous conservative surgery and radiotherapy (CS + RT) are usually offered autologous breast reconstruction. However, not all such patients are suitable candidates for a major flap reconstruction. The purpose of this study is to review our results of immediate 2-stage prosthetic breast reconstruction after CS + RT. Methods: A retrospective review was undertaken for 671 consecutive patients with prosthetic-only breast reconstruction performed by a single surgeon over a 12.5-year period. Twenty-two patients who qualified for the criteria were audited. Outcomes examined include complications, loss of tissue expander or implant, revisional surgery, and aesthetic result. Results: Twenty-two patients underwent 33 mastectomies and immediate 2-stage breast reconstructions after previous CS + RT (15 for recurrent cancer and seven “risk-reduction”) and 11 contralateral risk-reducing mastectomies. One patient died due to extensive metastatic disease. There was no reconstruction failure. The average breast implant size was 491.7 g (range 220 -685g). Seroma was the most common complication and occurred in 3 of 22 patients (13.6%) after stage 1 and 3 of 21 patients (14.3%) after stage 2 reconstruction. The revisional surgery rate was 28.6%. Aesthetic result was rated as excellent in 9.5%, good in 76.2%, and fair in 14.3%. Conclusions: For selected patients, immediate 2-stage prosthetic breast reconstruction can be performed successfully after a salvage mastectomy subsequent to a recurrence after CS + RT.

What Would Women Choose When Given a Choice in Breast Reconstruction

Background: Reconstruction after mastectomy is an important milestone for many women treated for breast cancer. However, because many surgeons only offer their preferred method of reconstruction, it is not clear which approach women would choose if offered a genuine choice. Methods: Between 1998 and 2010, the breast reconstruction service at a major Australian teaching hospital was staffed by a single plastic surgeon trained in both prosthetic and autologous breast reconstruction techniques. The choices of all 837 women who underwent reconstruction were compared across time for publicly and privately funded patients using binary logistic regression. Results: Overall, women chose prosthetic over autologous reconstruction at a ratio of 4.7:1. This ratio increasingly favored prosthetic reconstruction over time, though less strongly for private patients who did not face a 3-year waiting list for autologous reconstruction. Conclusions: Financial constraints affected these women’s reconstruction choices. Nevertheless, and in contrast to the situation in the United States, these women clearly favored prosthetic over autologous reconstruction.

Evaluation of AirXpanders for Breast Reconstruction: Early Experience from Sydney

Aim: Two-staged prosthetic breast reconstruction has become a popular option involving a series of saline injections to expanders to create a pocket large enough for a permanent implant. This, however, requires frequent visits to the surgeon and numerous needle pricks with potential infection risk. A new form of tissue expander, the AirXpanders, has recently been trialed in Perth and the United States. It uses a remote-controlled release of compressed CO2 where needle punctures are avoided. Methodology: Prospective data were collected on the first 10 patients to have the AirXpanders implant inserted for breast reconstruction at Western Sydney. The implants were inserted subpectorally as the saline expanders, and patients were instructed how to use the remote 4 weeks postoperation. Results: Ten patients (4 immediate and 6 delayed) aged between 30 and 65 (mean, 48.3 years) underwent 14 AirXpanders insertions. One patient passed away due to metastatic malignancy. With the remaining patients, the average period of active expansion was 15.8 days (r, 6–21). The average size of final implant used was 451u2009g (r, 195–685). The only complications were 2 seromas. Conclusion: Our early results are consistent with the Perth trial. The new AirXpanders is safe to use and able to achieve satisfactory tissue expansion faster than saline expander. It also has the advantage of patient self-controlled without the need for multiple medical reviews and needle punctures.

Silicone breast implants are thicker than water.

1 Silicone Breast Implants Are Thicker than Water Sir: S gel breast implants have conventionally been categorized by volume in cubic centimeters (cm3/ml). This tradition has persisted until McGhan started manufacturing their anatomical cohesive gel implants. Since 2001, all McGhan implants, round or anatomical, are categorized in mass (g), whereas the Mentor implants remained unchanged with the volume (cm3/ml) categorization. The McGhan representatives, however, maintain that their silicone gel breast implants measured in grams can be virtually taken as the same as cm3/ml. They believe that the mass:volume ratio of these implants is close to 1:1, much like water. Nonetheless, the final breast sizes of augmentation, mammaplasty, or reconstruction seem to be smaller than expected when assuming mass equals to volume. We therefore acquired the most commonly used breast implants and measured their actual mass, volume, and density. The implants evaluated included McGhan (Styles 410, CML, MLP, SLD) and Mentor (Styles CPG, Siltex, SR). Investigations or any such activities pertinent to producing this study were carried out to a high ethical standard. Implants were measured on digital scales for their actual mass (g). With controlled temperature at 20°C, each implant was dipped into a full beaker containing pure ethanol (density = 0.7891). As the density of any implants is higher than pure ethanol, all implants sink. Based on the Archimedes principle of displacement, volume of the displaced ethanol captured would equal to volume of the sink implant. Density of each implant was subsequently calculated from the actual mass and the displaced ethanol volume (g/ml). Both McGhan’s (Table 1) and Mentor’s (Table 2) textured anatomical, textured round, and smooth round implants were examined. Table 1 demonstrates McGhan implants’ stated mass, actual mass, volume, density, and discrepancy. The discrepancy, varies from 7 to 15 ml, is to highlight the difference between the measured volume and the stated mass. In 2009, Allergan sold 287 million US dollar worth of breast aesthetic products.2 Allergan and Mentor dominated the global medical aesthetic devices market with a combined share of 40%.3 The categorization method McGhan adopted has significant impact on global breast surgery. Our observation of the final breast size disparity caused by this policy was confirmed by the experiment. All silicone breast implants tested are denser than water. Moreover, the density of silicone implants is not always uniform. Even within the same model of implants (McGhan Style 410), their densities vary from 1.02 to >1.07 g/ml depending on the mass of the implants (Table 1). Furthermore, textured implants seem to be slightly denser than the smooth implants with similar mass. This, however, needs to be proven with a bigger scale of study. Presented, in part, at the following Academic Meetings: 13th World Congress of the International Confederation for Plastic Reconstructive and Aesthetic Surgery, Sydney, Australia, August 2003; and Annual Scientific Congress of the Royal Australasian College of Surgeons, Brisbane, Australia, May 2003. Copyright

Two-stage prosthetic breast reconstruction after mastectomy with or without prior postmastectomy radiotherapy

Background: Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period. Methods: Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded. Results: Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections. Conclusions: Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.