Clinical Physiology of Circulation

ISSN 1814-6910 (Print)
ISSN 2410-9134 (Online)

 

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Issue's catalogue ➤ КФК. 2023; 20 (4): 321-410 ➤ Результаты хирургического лечения и осложнения после резекционно-пластических операций при деформирующей форме лимфедемы

Results of surgical treatment and complications after resection and plastic surgery for deforming lymphedema

Authors: Malinin A.A., Bagyan A.R., Sergeev S.Yu.

Company:
Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

DOI: https://doi.org/10.24022/1814-6910-2023-20-4-390-402

UDC: 616.36-005.98-089-06

Link: Clinical Physiology of Blood Circulaiton. 2023; 4 (20): 390-402

Quote as: Malinin A.A., Bagyan A.R., Sergeev S.Yu. Results of surgical treatment and complications after resection and plastic surgery for deforming lymphedema. Clinical Physiology of Circulation. 2023; 20 (4): 390–402 (in Russ.). DOI: 10.24022/1814-6910-2023-20-4-390-402

Keywords:  chronic lymphedema lymphedema slough massive localized lymphedema resection and plastic surgery deforming form of lymphedema autotransplantation of skin plastic surgery with local tissues determination of blood supply to tissues tissue viability

Received / Accepted:  28.10.2023 / 24.11.2023

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Abstract

Objective. To analyze the results of reduction operations with plastic surgery using local tissues in patients with deforming forms of lymphedema.

Material and methods. Over a 20-year period, 110 patients with deforming or massive localized forms of primary and secondary lymphedema were treated, who underwent 173 resection and plastic surgeries with wound plastic surgery using local tissues. In 70 patients with deforming lymphedema of the upper limb, 125 operations were performed in stages, and in the remaining 40 patients, 48 operations were performed on various segments of the lower limb. Treatment of deforming forms of lymphedema was carried out in two stages. At the first stage, conservative methods of complex therapy of lymphatic edema were used for maximum reduction of edema. The second stage consisted of surgical removal of excess skin and lymphedema tissues with plastic surgery using local tissues, for which a traction technique was used to tighten the edges of the wound.

Results. Surgical reduction of tissue volume led to a decrease in limb circumference, which in percentage terms averaged 81.1 ± 6.7% for the upper limb segments, and 79.3 ± 6.6% for the lower limb. Of 173 resection-plastic operations with wound plastic surgery using local tissues in the postoperative period, marginal skin necrosis was present in 24 (13.9%), partial necrosis of the skin flap in 6 (3.5%) and extensive death a total of partially mobilized skin flap in 4 (2.3%) cases. During dynamic observation in the postoperative period, the cumulative percentage of complete survival of skin flaps and the absence of the development of necrotic complications was 79.7%.

The increase in treatment time for marginal necrosis of the skin flap was 1.4 times, for partial necrosis 2.0 times, and for extensive tissue death of the skin flap 2.8 times.

Conclusion. Treatment of deforming forms of lymphedema is impossible without excision of excess skin tissue and lymphedema subcutaneous fat. In extreme cases of lymphedema, classical methods of compression therapy have only staged effectiveness and are used to remove stagnant lymph from tissues. To restore the natural size of the affected limb, the method of surgical reduction of excess tissue and various types of skin plastic surgery are used.

References

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****
  1. Ba-Shammakh S.A., Haj-Freej H.M., Al-Naggar Y.S., Waleed Ghanem, Manal Z. Haij, Fahmi Al-Mohd et al. Massive localized lymphedema: two case studies and diagnostic challenges. Cureus. 2023; 15 (10): e47092. DOI: 10.7759/cureus.47092
  2. Ramachandran S., Chew K.Y., Tan B.K., Kuo Y.R. Current operative management and therapeutic algorithm of lymphedema in the lower extremities. Asian J. Surg. 2021; 44: 46–53. DOI: 10.1016/j.asjsur.2020.08.010
  3. Ciudad P., Escandón J.M., Manrique O.J., Bustos V.P. Lessons learnt from an 11-year experience with lymphatic surgery and a systematic review of reported complications: technical considerations to reduce morbidity. Arch. Plastic Surg. 2022; 49 (02): 227–39. DOI: 10.1055/s-0042-1744412
  4. Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016; 49 (4): 170–84.
  5. Malinin A.A., Pryadko S.I., Peskova A.S., Papitashvili V.G., Chomaeva A.A. Wound closure by skin traction in patients with elephantiasis of extremities. Flebologiya. 2022; 16 (4): 279–88 (in Russ.). DOI: 10.17116/flebo202216041279
  6. Rajan S., Venkatramani H. Recent advances in management of lymphedema. J. Skin Sex. Transmit. Dis. 2021; 3 (1): 26–32.
  7. Krishnasamy K., Abdullah H.S., Chinna K. Lower limb lymphedema successfully treated with flap monitoring – a case report. Int. J. Sci. Med. Res. 2022; 2 (4): 12–5. DOI: 10.55349/ijmsnr.2022241215
  8. Drobot D., Zeltzer A.A. Surgical treatment of breast cancer related lymphedema – the combined approach: a literature review. Gland. Surg. 2023; 12 (12): 1746–59. DOI: 10.21037/gs-23-247
  9. Schaverien M.V., Coroneos C.J. Surgical treatment of lymphedema. Plast. Reconstr. Surg. 2019; 144 (3): 738–58.
  10. Gallagher K.K., Lopez M., Iles K., Kugar M. Surgical approach to lymphedema reduction. Curr. Oncol. Rept. 2020; 22: 1–13.
  11. Park K.E., Allam O., Chandler L., Mozzafari M.A., Ly C., Lu X., Persing J.A. Surgical management of lymphedema: a review of current literature. Gland. Surg. 2020; 9: 503–11. DOI: 10.21037/gs.2020.03.14
  12. Singh K., Kania T., Kimyaghalam A., Breier Y., Cooper M. How I do it: radical debulking of lower extremity end-stage lymphedema. J. Vasc. Surg. Cas. Innovat. Tech. 2023; 9 (3): 101238. DOI: 10.1016/j.jvscit.2023.101238
  13. Chopra K., Tadisina K.K., Brewer M., Holton L.H., Banda A.K., Singh D.P. Massive localized lymphedema revisited: a quickly rising complication of the obesity epidemic. Ann. Plast. Surg. 2015; 74 (1): 126–32.
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  15. Júnior С.W., Modolin M.L.A., Rocha R.I., Fernandes T.R., Nogueira A.B., Gemperli R., Ferreira M.C. Results of surgical treatment of massive localized lymphedema in severely obese patients. Rev. Col. Bras. Cir. 2014; 41 (1): 018–022. DOI: 10.1590/S0100-69912014000100005
  16. Asch S., James W.D., Castelo-Soccio L. Massive localized lymphedema: an emerging dermatologic complication of obesity. J. Am. Acad. Dermatol. 2008; 59 (Suppl. 5): 109–S110.
  17. Moore E., Vasconez H., Wong L. Massive localized lymphedema: analysis of intraoperative care. Ann. Plastic Surg. 2018; 81 (1): 75–9. DOI: 10.1097/SAP.0000000000001475
  18. Gebremariyam Z.T., Woldemichael N.A. Staged surgical management of advanced leg lymphedema: a successful Charles procedure in a resource-limited setting, case report. Intern. J. Surg. Case Rep. 2024; 115: 109221 DOI: 10.1016/j.ijscr.2024.109221
  19. Mir M.A., Mahakalkar S.S., Rashim M. Modified combined physiological and debulking procedure for lower limb lymphedema to achieve both immediate and sustained results in lymphedema. Intern. J. Lower Extrem. Wounds. 2023; 22 (1): 194–9. DOI: 10.1177/15347346211002367
  20. Misra S., Carroll B.J. Comprehensive approach to management of lymphedema. Curr. Treat. Options Cardio. Med. 2023; 25: 245–60. DOI: 10.1007/s11936-023-00991-8
  21. Hassan K., Chang D.W. The Charles procedure as part of the modern armamentarium against lymphedema. Ann. Plast. Surg. 2020; 85 (6): e37–e43. DOI: 10.1097/ SAP.0000000000002263
  22. Karlsson T., Mackie H., Koelmeyer L., HeydonWhite A., Ricketts R., Toyer K. et al. Liposuction for advanced lymphedema in a multidisciplinary team setting in Australia: 5-year follow-up. Plast. Reconstr. Surg. 2024; 153 (2): 482–91. DOI: 10.1097/PRS.0000000000010612
  23. Ogawa A., Nakagawa T., Oda G., Hosoya T., Hayashi K., Yoshino M. et al. Study of the protocol used to evaluate skin-flap perfusion in mastectomy based on the characteristics of indocyanine green. Photodiagn. Photodynam. Ther. 2021; 35: 102401. DOI: 10.1016/j.pdpdt.2021.102401
  24. Cormier J.N., Rourke L., Crosby M., Chang D., Armer J. The surgical treatment of lymphedema: a systematic review of the contemporary literature (2004–2010). Ann. Surg. Oncol. 2012; 19: 642–51. DOI: 10.1245/s10434- 011-2017-4
  25. Wang M.L., Valenti A.B., Qin N., Vernice N.A., Huang H., Cohen L.E., Otterburn D.M. Using clinical measurements to predict breast skin necrosis: a quantitative analysis. Ann. Plast. Surg. 2023; 90 (2): 163–70. DOI: 10.1097/SAP.0000000000003363
  26. Kim H., Park S.J., Woo K.J., Bang S.I. Comparative study of nipple-areola complex position and patient satisfaction after unilateral mastectomy and immediate expander-implant reconstruction nipple-sparing mastectomy versus skin-sparing mastectomy. Aesthetic Plast. Surg. 2019; 43: 313–27. DOI: 10.1007/s00266-018-1217-8
  27. Özsoylu D., Janus K.A., Achtsnicht S., Wagner T., Keusgen M., Schöning M.J. (Bio-) Sensors for skin grafts and skin flaps monitoring. 2023; Sens. Actuat. Rep. 2023; 6: 100163. DOI: 10.1016/j.snr.2023.100163
  28. Rosa B.G., Akingbade O.E., Guo X., Gonzalez-Macia L., Crone M.A., Cameron L.P. et al. Multiplexed immunosensors for point-of-care diagnostic applications. Biosens. Bioelectron. 2022; 203: 114050. DOI: 10.1016/j.bios.2022.114050
  29. Gogia B., Chekmareva I., Leonova A., Alyautdinov R., Karmazanovsky G., Glotov A., Kalinin D. Massive localized abdominal lymphedema: a case report with literature review. Arch. Plast. Surg. 2023; 50 (06): 615–20. DOI: 10.1055/a-2140-8589.eISSN 2234-6171
  30. Juneja A., Singh K., Cooper, M., Guerges M., Schor J., Deitch J. Quality of life is improved with radical debulking for severe chronic lymphedema. J. Vasc. Surg. 2020; 72 (1): e240–e241.
  31. Abalmasov K.G., Malinin A.A. Clinical classification of lymphedema. Vestnik of Lymphology. 2006; 1: 7–10 (in Russ.).
  32. Charles H. Elephantiasis of the leg. In: Latham A., English T.C. (Eds). A system of treatment. Vol. 3. London: Churchill; 1912.
  33. Homans J. Treatment of elephantiasis of the leg. N. Engl. J. Med. 1936; 215: 1099.
  34. Wada H., Vargas C.R., Angelo J., Faulkner-Jones B., Paul M.A., Ho O.A. et al. Accurate prediction of tissue viability at postoperative day 7 using only two intraoperative subsecond near-infrared fluorescence images. Plast. Reconstr. Surg. 2017; 139: 354–63. DOI: 10.1097/PRS.0000000000003009
  35. Nguyen J.T., Ashitate Y., Venugopal V., Neacsu F., Kettenring F., Frangioni J.V. et al. Near-infrared imaging of face transplants: are both pedicles necessary? J. Surg. Res. 2013; 184: 714–21. PubMed: 23706565
  36. Matsen C.B., Mehrara B., Eaton A., Capko D., Berg A., Stempel M. et al. Skin flap necrosis after mastectomy with reconstruction: a prospective study. Ann. Surg. Oncol. 2016; 23: 257–64. DOI: 10.1245/s10434-015-4709-7
  37. Vargas C.R., Koolen P.G., Anderson K.E., Paul M.A., Tobias A.M., Lin S.J. et al. Mastectomy skin necrosis after microsurgical breast reconstruction. J. Surg. Res. 2015; 198: 530–4. PubMed: 25913487
  38. Yabe S., Nakagawa T., Oda G., Ishiba T., Aruga T., Fujioka T. et al. Association between skin flap necrosis and sarcopenia in patients who underwent total mastectomy. Asian J. Surg. 2020; 44: 465–70. DOI: 10.1016/j.asjsur.2020.11.001
  39. Salgado C.J., Sassu P., Gharb B.B., di Spilimbergo S.S., Mardini S., Chen H.C. Radical reduction of upper extremity lymphedema with preservation of perforators. Ann. Plast. Surg. 2009; 63: 302–6. DOI: 10.1097/SAP.0b013e31818d45aavSiegel J.А., Zhao L., Tachibana I., Carlson S., Tausch T.J., Klein A.K. et al. Rapid excision of massive localized lymphedema of the male genitalia with vessel sealing device. Can. J. Urol. 2016; 23 (3): 8291–5.
  40. Miller T.A., Wyatt L.E., Rudkin G.H. Staged skin and subcutaneous excision for lymphedema: a favorable report of long-term results. Plast. Reconstr. Surg. 1998; 102 (5): 1486–98.

About Authors

  • Aleksandr A. Malinin, Dr. Med. Sci., Chief Researcher; ORCID
  • Arut R. Bagyan, Postgraduate; ORCID
  • Stanislav Yu. Sergeev, Cardiovascular Surgeon; ORCID

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