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. 2023 Aug 2;50(4):422-431.
doi: 10.1055/s-0043-1768645. eCollection 2023 Jul.

A Comprehensive Approach to Posttraumatic Lymphedema Surgical Treatment

Nicolás Pereira  1   2 , Vanessa Oñate  1   2 , Ricardo Roa  1
Affiliations

A Comprehensive Approach to Posttraumatic Lymphedema Surgical Treatment

Nicolás Pereira et al. Arch Plast Surg. .

Abstract

Background Posttraumatic lymphedema (PTL) is sparsely described in the literature. The aim of this study is to propose a comprehensive approach for prevention and treatment of PTL using lymphovenous anastomosis (LVA) and lymphatic vessels free flap, reporting our experience in the management of early-stage lymphedema. Methods A retrospective observational study was performed between October 2017 and July 2022. Functional assessment with magnetic resonance lymphangiography and indocyanine green lymphography was performed. Patients with lymphedema and functional lymphatic channels were included. Cases with limited soft tissue damage were proposed for LVA, and those with acute or prior soft tissue damage needing skin reconstruction were proposed for superficial circumflex iliac artery perforator lymphatic vessels free flap (SCIP-LV) to treat or prevent lymphedema. Primary and secondary outcomes were limb volume reduction and quality of life (QoL) improvement, respectively. Follow-up was at least 1 year. Results Twenty-eight patients were operated using this approach during the study period. LVA were performed in 12 patients; mean reduction of excess volume (REV) was 58.82% and the improvement in QoL was 49.25%. SCIP-LV was performed in seven patients with no flap failure; mean REV was 58.77% and the improvement QoL was 50.9%. Nine patients with acute injury in lymphatic critical areas were reconstructed with SCIP-LV as a preventive approach and no lymphedema was detected. Conclusion Our comprehensive approach provides an organized way to treat patients with PTL, or at risk of developing it, to have satisfactory results and improve their QoL.

Keywords: SCIP flap; lymphedema; lymphovenous anastomosis; posttraumatic lymphedema; supermicrosurgery.

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Conflict of interest statement

Conflict of Interest None declared.

Figures

Fig. 1
Fig. 1
Posttraumatic lymphedema algorithm for surgical treatment. In this study, we include early-stage lymphedema with functional lymphatic channels. ICG-L, indocyanine green lymphography; LVA, lymphovenous anastomosis; MR-L, magnetic resonance lymphangiography; TEAR, total extremity anatomy reconstruction; VLNT, vascularized lymph node transfer; VLVT, vascularized lymphatic vessels transfer; TEAR, total extremity anatomy reconstruction..
Fig. 2
Fig. 2
Indocyanine green lymphography (ICG-L) of the inguinal area to study the lymphatic vessels anatomy of the SCIP-LV for preoperative planning. ( A ) ICG-L of the groin. ( B ) SCIP-LV free flap markings for TEAR approach. The asterisks (*) show ICG injecting sites. ASIS, anterior superior iliac spine; SCIP-LV, superficial circumflex iliac artery perforator lymphatic vessels; TEAR, total extremity anatomy reconstruction.
Fig. 3
Fig. 3
SCIP-LV free flap inset. ( A ) The lymphatic system of the groin drains from lateral to medial. ( B ) The medial aspect of the flap was placed in a proximal location of the extremity defect and the lateral aspect in a distal location. SCIP-LV, superficial circumflex iliac artery perforator lymphatic vessels.
Fig. 4
Fig. 4
Nonlymphatic reconstruction with an ALT flap without considering the axiality of the lymphatic drainage. ( A ) Left leg lymphedema distal to ALT flap. ( B ) Lymphatic dysfunction assessed with ICG-L. The arrow indicates pitting edema, the asterisks (*) show ICG injecting site in foot web spaces, and the star indicates the medial malleolus. ALT, anterolateral thigh flap; ICG-L, indocyanine green lymphography.
Fig. 5
Fig. 5
A 28-year-old female patient with 2 years of left lower limb posttraumatic lymphedema after an orthopaedic surgery treated with three lymphovenous anastomosis. ( A ) Preoperative excess volume (PEV) was 8.68%. ( B ) Twelve months after surgery, PEV was 0.12% and the reduction of excess volume was 98.54% (Patient 1 in Table 1 ).
Fig. 6
Fig. 6
A 58-year-old male patient with 6 years of right lower limb posttraumatic lymphedema after a tiger attack treated with three lymphovenous anastomosis. ( A ) Preoperative excess volume (PEV) was 13.35%. ( B ) Thirteen months after surgery, PEV was 7.37% and the reduction of excess volume was 44.7% (Patient 3 in Table 1 ).
Fig. 7
Fig. 7
Case 3. ( A ) Preoperative picture. ( B ) Twenty-month postoperative picture. A 42-year-old male patient with 10 months of right upper limb posttraumatic lymphedema and chronic ulcer after a degloving injury treated with local flaps. Scarred tissue was excised and reconstruction was performed with TEAR approach using SCIP-LV. ( A ) Preoperative excess volume (PEV) was 19.25%; ( B ) Twenty months after surgery, PEV was 5.55% and the reduction of excess volume was 71.17% (patient 2 in Table 2 ). SCIP-LV, superficial circumflex iliac artery perforator lymphatic vessels; TEAR, total extremity anatomy reconstruction.
Fig. 8
Fig. 8
A 52-year-old male patient with right arm injury in a critical lymphatic area secondary to spider bite. ( A ) Necrotic tissue was excised and a preventive TEAR approach using SCIP-LV was performed. ( B ) Fourteen months after surgery, no lymphedema is seen on the right upper limb (patient 2 in Table 3 ). The arrow indicates SCIP flap location. SCIP-LV, superficial circumflex iliac artery perforator lymphatic vessels; TEAR, total extremity anatomy reconstruction
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References

    1. Szczesny G, Olszewski W L. The pathomechanism of posttraumatic edema of lower limbs: I. The effect of extravasated blood, bone marrow cells, and bacterial colonization on tissues, lymphatics, and lymph nodes. J Trauma. 2002;52(02):315–322. - PubMed
    1. Bräutigam P, Földi E, Schaiper I, Krause T, Vanscheidt W, Moser E. Analysis of lymphatic drainage in various forms of leg edema using two compartment lymphoscintigraphy. Lymphology. 1998;31(02):43–55. - PubMed
    1. Mostbeck A, Partsch H.[Isotope lymphography–possibilities and limits in evaluation of lymph transport] Wien Med Wochenschr 1999149(2–4):87–91. - PubMed
    1. van Zanten M C, Mistry R M, Suami H et al.The lymphatic response to injury with soft-tissue reconstruction in high-energy open tibial fractures of the lower extremity. Plast Reconstr Surg. 2017;139(02):483–491. - PubMed
    1. Pereira N, Cámbara Á, Kufeke M, Roa R. Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: a case report. Microsurgery. 2019;39(04):354–359. - PubMed