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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3628_Библиотеки_им_академика_М_И_Перельмана
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Preface
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Our personal experience is based upon the fact
that patients must be always well informed, in order
to develop realistic expectations after individual
work-up, including pursuing CDT following surgery.
Accordingly, we are particularly proud that several
international experts in the field from around the
world have contributed to this book and have shared
their knowledge and experience, which is addressed
not only to surgeons—young or old—involved and
interested in the overall surgical management of
chronic lymphedema, but to all professionals dealing
with lymphedema patients.
The first chapters of this book have been reserved
for the understanding of embryology, anatomy and
physiology of the healthy lymphatic system. The next
chapters focus on diagnosis, preoperative evaluation
and treatment indication of chronic lymphedema. Further, conservative treatment is presented in particular
as an integral component of surgical lymphedema
treatment. Above all, reconstructive procedures, such
as lymphovenous and lympho-lymphatic anastomoses
as well as autologous lymph vessel and lymph-node
transfer are discussed. Finally, teaching and training
in reductive and lympho-reconstructive surgery,
secondary procedures af ter reconstructive micro surgery, review of the present literature and outlook on current research in lymphology round off
the content.
This textbook is no substitute for what a skilled
surgeon should be lear ning in dedicated courses or
at the operation table under the supervision of
a surgical teacher. The decisive writing and its
consistent illustration are however intended to
improve the understanding of the principles and
philosophy of modern surgical management of
chronic lymph ede ma.
Enjoy reading, discussing, and improving the outcome of future patients of this striving field!
The Editors
Lugano, Frankfurt am Main, Düsseldorf, Brussels, 2024
Personal Prefaces
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It is all about personal curiosity, perseverance, and
improving the patient's quality of life...
I first came into contact with reconstructive microsurgery for lymphedema in 2010. After studying
the scarce literature available at that time, participating in meetings, in which I shyly initiated discussions
about lympho-reconstructive surgery, and visiting
Corinne Becker in Paris, my former professor and a
surgical colleague gave me the opportunity to participate in the build-up of a lympho-reconstructive unit.
This pioneering work executed in Germany allowed us to gain experience from the first 100 cases
in a rather short time. Despite the fascination of this
rewarding surgery, at the beginning we obviously
suffered some setbacks. Initially, we were too
focused on reducing volume and recreating the
shape of the affected extremity. It took us some time
to understand that the patients were often desperate
and therefore more than happy after surgery, especially if they could reduce the number of visits to the
physiotherapist or decrease the grade and time of
compression of their arm or leg.
Thorough follow-up of the patients and constant
inter-professional exchange with physiotherapists,
lymphologists and internist s allowed me, over
time, to better un der st and not only this chronic
and debilitating disease, but also, and foremost,
the needs of the patients. These recurrent discussions with professionals also made clear to these
“non-surgeons” that the few surgeons performing
this type of surgery would never dispossess them
of their chronic patients. They are simply far too
many!
Nowadays, almost every important meeting in surgery in general, and plastic surgery in particular,
dedicates scientific time to discussing standards and
progress in this field.
Accordingly, I am happy and proud to have set the
stage to bring together friends and colleagues that
share their passion for this very specific and yet
complex inter-professional and inter-disciplinary
medical field that deserves more attention due to its
worldwide socio-economic impact.
Yves Harder
Lugano, 2024
xx
Personal Prefaces
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It is all about being presented with an opportunity,
always…
The lymphatic system and its anatomical-functional str uctures have long been neglected in all
disciplines of medicine as the third vascular system alongside arteries and veins, and little attention was paid to it. It was finally the knowledge of
the importance and role of the lymphatic system
in tumorigenesis and metastasis that brought the
anatomical structures and the lymphatic fluid into
the focus of science, which Thomas Mann had described more than two centuries ago as the “very
finest, most intimate and most delicate in the
whole body.”
I experienced something similar myself:
In my doctoral thesis, the lymphatic system was
more of a means for obtaining the Dr. med. title. By
coincidence and through a conversation with my
Berlin mentor at the time, a more or less voluntary
transfer of a scientific project in my first surgical
position meant the continuation of this trajectory.
While I was initially abl e to evaluate ICG lymphangiography for t umor staging and sentinel lymph
node biopsy from a general surgical perspect ive in
2007, over the past 15 years the technique has developed into an indispensable tool for simple, reliable real-time imaging of the lymphatic system.
My switch to plastic surgery in 2009 to Ludwigshafen/Germany and the enthusiasm and possibilities
in microsurgery have not let go of me since then,
and have triggered and imparted a true fascination
and passion.
I am grateful and humbled, at the same time, to
have met many companions with the same passion
and enthusiasm for reconstructive microsurgery of
lymphedema and to have found to be valued colleagues, friends and collaborators. Numerous latenight discussions with peers have steadily developed
my own perspective on this particular field, which is
an ongoing, never-ending process.
Despite the possibilities of lymphatic surgery, lymphedema is and remains the most significant
consequence of oncological treatment of malignant
tumors and a large infectiou s burden, and leads to
disfigurement, loss of integrity and reduced quality of life, function, form and aesthetics.
I am both grateful and happy to be the co-editor of
this book, with many outstanding authors and surgeons, and make a contribution to enabling as many
patients as possible to receive the best possible individual, targeted and effective treatment for lymphedema
and to encourage and excite young microsurgeons to
work in this field, as it continuously excites me.
Christoph Hirche
Frankfurt am Main, 2024
It is all about passion…
I am very fortunate and grateful that my profession
is my passion. My favorite place is and has been the
OR, where I get to perform surgeries with colleagues
who I am able to call my friends. Having happy and
thankful patients makes the daily work routine even
more enjoyable.
I would like to say thank you to all my teachers—
my personal heroes and idols—and to all the valuable companions who share the same dreams. You
have, in the meantime, become true friends.
During my education, I have been lucky enough
to have had the ch ance to travel and to visit various
pioneers of microsurgery. I started with a fellowship in Ghent (Belgium), with P. Blondeel and M.
Hamdi, where they did not only teach me micro surgery, but also passed their passion for it on
to m e.
In 2010, I visited the first lymphedema meeting
in Barcelona, where the definition supermicrosur-
gery was born. The pioneers, Koshima, Becker and
Brorson, and the host Masia, talked about this new
chapter in microsurgery. Infected by their fascination,
I then discovered back home that we also had
many patients suffering from breas t cancer-related
lymphedema–I had not recognized the connection
in that way before.
A lot of travelling followed: I went to Corinne in
Paris, to Jaume in Barcelona, to Håkan in Malmö and
then, step by step, I started lymphedema surgery in
Germany and Brussels.
Thank you to all of you who shared your knowledge with me. Thank you, Christoph Andree, for
always letting me travel and trusting me to build a
lymphedema unit in Düsseldorf.
I would like to advise all young enthusiastic plastic
surgeons to visit the masters and to believe in your
dreams. In that way, you will gain experience and
grow into a coping and responsible person, and, as a
positive side factor, you will also gain wonderful
friends who share your passion.
Finally, I would like to thank my family. Thank you
for understanding that my profession always comes
first. Thank you for supporting me on my journey and
giving me the “time and the freedom” to focus on my
passion.
Katrin Seidenstücker
Düsseldorf, 2024
Personal Prefaces
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To the forgotten patients…
It was Gent, 2006. My friends, Koen Van Landuyt,
Corrine Becker and I had succeeded in performing
the first conjoined free DIEP flap breast reconstruction with a vascularized groin LN flap transfer in history. This was my first contact with such pathology,
“Lymphedema.”
One year later, Corrine asked me help to organize
a VLNT in my motherland, Syria, for an 18-year-old
patient with a post-trauma lower extremity lymphedema. There was considerable soft tissue/skin
loss with extended scar-tissue, so I decided to harvest a DIEP flap to reconstruct the missing part together with the VLNT . The surgery was successfully
carri ed out. The young patient, “Maha,” later became a medical student!
These two cases opened my eyes and mind with
respect to extremely challenging surgery.
I also subsequently found out that lymphedema
patients do not receive the same attention as breast
reconstruction patients:
I named them, “the forgotten patients.”
Exchanges and experiences with my international
colleagues taught me that surgery is not enough to
help those patients, and that a multidisciplinary
approach is mandatory, if better outcomes are to be
achieved. In 2016, after 10 years of hard work, I succeeded in opening a lymphedema clinic within my
plastic surgery department in Brussels. De Lymfklinik
is a unique model and magic mixture between surgical
activities, clinical research, and patient services. To
be sure, this could not have been achieved without
a great team. I am s o grateful to our nurses, secretaries, physiotherapists, trainees, and mainly to my
staff members who built up the European C enter of
Lymphatic Surgery (Assaf Zeltzer, Katrin Seidenstücker, Randy Debaerdemaeker, and more recently,
Alex Nistor).
Moustapha Hamdi
Brussels, 2024
xxii
List of Abbreviations
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ALND: a xillary lymph node dissection
ALVT: autologous lymph vessel transfer
ASIS: anterosuperior iliac spine
CCL21: chemokine ligand 21
CCR7: chemokine receptor 7
CDT: complete decongestive therapy
CNS: central nervous system
COUP-TFII: COUP transcription factor 2
CTA: computed tomography angiography
CXCR4: chemokine receptor 4
DB: dermal backflow
DC: dendritic cell
DIEP: deep inferior epigastric perforator
EGF: epidermal growth factor
ERK1/2: extracellular signal–regulated kinases 1/2
FCI: fasciocutaneous infragluteal
FGF: fibroblast growth factor
FOXC2: forkhead box protein C2
HGF: hepatocyte growth factor
HIF1α: hypoxia-inducible factor 1α
ICG: indocyanine green
IGAP: inferior gluteal artery perforator
IGF-1: insulin-like growth factor 1
ISL: International Society of Lymphology
LAP: lumbar artery perforator
LEC: lymphatic endothelial cell
LN: lymph node
LNU: lymph node unit
LNVA: lymph node to vein anastomosis
LSG: radionuclide lymphoscintigraphy
LV: lymphatic vessel
LVA: lymphovenous anastomosis
LYMPHA: lymphatic microsurgical preventive
healing approach
LYVE-1: lymphatic vessel endothelial hyaluronan
receptor 1
MALT: mucosa-associated lymphoid tissue
MAPK3: mitogen-activated protein kinase 3
MINORS: methodological index for
randomized studies
MLD: manual lymph drainage
MRL: magnetic resonance lymphangiography
NFARc1: nuclear factor of activated T-cells
cytoplasmic 1
NRP2: neuropilin 2
PAP: profunda artery perforator
PDGF-B: platelet-derived growth factor B
PROX1: prospero homeobox protein 1
SAPD: suction-assisted protein lipectomy
SCIA: superficial circumflex iliac artery
SCIV: superficial circumflex iliac vein
SFJ: sapheno-femoral junction
SGAP: superior gluteal artery perforator
SIEV: superficial inferior epigastric vein
S1P: sphingosine-1-phosphate
S1PR1: sphingosine-1-phosphate receptor 1
S1PR3: sphingosine-1-phosphate receptor 3
SLNB: sentinel lymph node biopsy
SLO: secondary lymphatic organ
SMC: smooth-muscle cell
SOX18: sex determining region Y box 18
SPECT-CT: single photon emission computed
tomography–computed tomography
TGF-β: transforming growth factor β
TI: transpor t index
T-BAR: total breast anatomy restoration
TMG: transverse myocutaneous gracilis
TUG: transverse upper gracilis
ULL-27: upper limb lymphedema 27
VEGF-C: vascular endothelial growth factor C
VEGF-D: vascular endothelial growth factor D
VEGFR-3: vascular endothelial growth factor
receptor 3
VLNT: vascularized lymph node transfer
Contributors
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Nele Adriaenssens, PT, PhD
Associate Professor
Department of Physiotherapy
Human Physiology and Anatomy (KIMA)
Faculty of Physical Education and
Physiotherapy–Rehabilitation Research Group
Vrije University Brussels;
Coordinator
Oncological Rehabilitation Program and
Edema Consultation
Medical Oncology Department
Universitair Ziekenhuis Brussel;
President
Belgian Society of Lymphology
Brussels, Belgium
Rüdiger G. H. Baumeister, MD
Former Professor and Head of Plastic, Hand, and
Microsurgery
Ludwig Maximilians University Munich;
Consultant in Lymphology
Urological Clinic Munich Planegg
Munich, Germany
Alessandro Bianchi, MD
Department of Plastic and Reconstructive Surgery
Università Cattolica del Sacro Cuore
Fondazione Policlinico Universitario Agostino
Gemelli IRCSS
Rome, Italy
Amir K. Bigdeli, MD
Department of Hand, Plastic, and
Reconstructive Surgery, Burn Center
BG Klinik Ludwigshafen
Plastic and Hand Surgery, University of Heidelberg
Ludwigshafen, Germany
Anja M. Boos, MD
Senior Physician and Deputy Director
Clinic for Plastic Surgery
Department of Plastic and Hand Surgery
University Hospital RWTH Aachen
Aachen, Germany
Pierre Bourgeois, MD, PhD, MCUH
Professor
Services of Nuclear Medicine, Vascular
Surgery and Dermatology
Institut J Bordet
HIS-IZZ Hospitals and University Hospital Erasme
Université Libre de Bruxelles
Brussels, Belgium
Håkan Brorson, MD, PhD
Senior Plastic Surgeon
Department of Plastic and Reconstructive Surgery
Skåne University Hospital
Malmö, Sweden;
Professor of Plastic Surger y
Department of Clinical Sciences
Lund University
Lund, Sweden;
Professor
Faculty of Medicine
La Escuela de Graduados de la Asociación Médica
Argentina (EGAMA)
Buenos Aires, Argentina
Carola Brussaard, MD
Department of Radiology
Universitair Ziekenhuis Brussel
Brussels, Belgium
Tomke Cordts, MD
Senior Physician
Department of Hand, Plastic, and Reconstructive
Surgery, Burn Center
BG Klinik Ludwigshafen
Plastic and Hand Surgery, University of Heidelberg
Ludwigshafen, Germany
Randy De Baerdemaeker, MD
Professor
Department of Plastic and Reconstructive Surgery
Vrije University Brussels
Brussels, Belgium
xxiv
Contributors
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Holger Engel, MD, FACS
Professor
Plastic, Reconstructive, and Aesthetic Surgery
ETHIANUM Clinic Heidelberg
Heidelberg, Germany
Andreas Frick, MD
Former Professor Senior Physician
Hand, Plastic and Aesthetic Surgery
University Hospital Munich (LMU)
Munich, Germany
Florian Früh, MD, FEBHS
Head of Hand and Plastic Surgery
Clinic for Plastic Surgery and Hand Surgery
Kantonsspital Aarau (KSA)
Aarau, Switzerland
Emre Gazyakan, MD, MSc, FEBOPRAS, FEBHS
Senior Consultant
Department of Hand, Plastic, and
Reconstructive Surgery, Burn Center
BG Klinik Ludwigshafen
Plastic and Hand Surgery, University of Heidelberg
Ludwigshafen, Germany
Jeremy A. Goss, MD
Postdoctoral Research Fellow
Department of Plastic and Oral Surgery
Boston Children’s Hospital
Boston, United States
Epameinondas Gousopoulo, MD, PhD
Department of Plastic Surgery and Hand Surgery
University Hospital Zurich
Zurich, Switzerland
Arin K. Greene, MD, MSc
Vascular Anomalies and Pediatric Plastic Surgery
Endowed Chair
Department of Plastic and Oral Surgery
Boston Children’s Hospital;
Professor of Surgery
Harvard Medical School
Boston, United States
Moustapha Hamdi, MD
Professor of Plastic Surger y
Head of the Department of Plastic Surgery and
Founder of Lymph Clinic
Brussels University Hospital
Brussels, Belgium;
Head of UZ Brussel-Chirec Joint-Network in
Plastic Surgery
Brussels, Belgium
Yves Harder, MD
Professor of Plastic Surger y
Head and Medical Director of the Department of
Plastic, Reconstructive, and Aesthetic Surgery
Ospedale Regionale di Lugano
Ente Ospedaliero Cantonale (EOC)
Lugano, Switzerland;
Faculty of Biomedical Sciences
Università della Svizzera Italiana (USI)
Lugano, Switzerland
Sarah Harnie, PT, MSc
Doctoral Thesis Student
Department of Physiotherapy
Human Physiology and Anatomy (KIMA)
Faculty of Physical Education and
Physiotherapy—Rehabilitation Research Group
Vrije University Brussels;
Consultant
Edema Consultation
Universitair Ziekenhuis Brussel
Medical Oncology Department
Brussels, Belgium
Pauliina Hartiala, MD, PhD
Docent for Surgery
Senior Research Fellow, MediCity
Turku University Hospital
Turku, Finland
Akitatsu Hayashi, MD
Plastic Surgeon
Department of Breast Center
Kameda Medical Center
Chiba, Japan
Contributors
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Christoph Hirche, MD, FACS
Professor of Plastic Surger y
Head of the Department of Plastic Surgery,
Hand Surgery, and Reconstructive Microsurgery
Hand Trauma and Replantation Center
BG Klinik Frankfurt am Main gGmbh
Frankfurt am Main, Germany
Katja Kilian, MD
Resident
Department of Hand, Plastic, and
Reconstructive Surgery, Burn Center
BG Klinik Ludwigshafen
Plastic and Hand Surgery, University of Heidelberg
Ludwigshafen, Germany
Leela Praveen Kumar, MD, MS, MCh
Consultant Plastic Surgeon
Apollo Hospitals
Chennai, India
Min-Seok Kwak, MD
Senior Physician and Deputy Director
Clinic and Polyclinic for Plastic Surgery and
Hand Surgery
Technical University of Munich
Rechts der Isar Hospital
Munich, Germany
Nicole Lindenblatt, MD
Professor
Deputy Clinical Director
Department of Plastic Surgery and Hand Surgery
University Hospital Zurich
Zurich, Switzerland
Hans-Günther Machens, MD
Professor and Director
Clinic and Polyclinic for Plastic Surgery and
Hand Surgery
Technical University of Munich
Rechts der Isar Hospital
Munich, Germany
Prof. Gurusamy Manokaran, MD, MS, MCh, FICS,
FRCS
Professor and Senior Consultant Plastic Surgeon
Apollo Hospitals
Chennai, India;
Chief of Lymphology Services
Department of Plastic and Reconstructive Surgery
Amrita Institute of Medical Sciences
Kochi, India;
Honorary Associate Professor
Macquarie University
Sydney, Australia
Jaume Masià, MD, PhD
Professor of Surgery
Autonomous University of Barcelona
Chief of the Plastic Surgery Department
Sant Pau University Hospital
Chief of the Comprehensive Lymphedema
Treatment Unit
Planas Clinic
Barcelona, Spain
Matteo Meroni, MD
Department of Hand- and Plastic Surgery
Luzerner Kantonsspital
Lucerne, Switzerland
Vincenzo Penna, MD
Medical Director
Penna Torio
Clinic for Plastic Surgery
Basel, Switzerland;
Professor of Plastic Surger y
Clinic of Plastic and Hand Surgery
University Medical Center Freiburg
Freiburg, Germany
Claus Christian Pieper, MD
Department of Radiology
University Hospital Bonn
Bonn, Germany
Cristhian D. Pomata, MD, MSc
Attending Plastic Surgeon
Comprehensive Lymphedema Treatment Unit
Planas Clinic
Barcelona, Spain
xxvi
Contributors
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Elena Rodríguez-Bauza, MD
Plastic Surgery Department
Hospital Universitario Son Espases
Barcelona, Spain
Julia Roka-Palkovits, MD
Senior Physician
Plastic, Reconstructive and Aesthetic Surgery
Krankenhaus Göttlicher Heiland
Vienna, Austria
Anne Saaristo, MD, PhD
Department of Plastic and General Surgery
Turku University Hospital
Turku, Finland
Marzia Salgarello, MD
Professor
Plastic and Reconstructive Surgeon
Department of Surgical Sciences
Università Cattolica del Sacro Cuore
Fondazione Policlinico Universitario Agostino
Gemelli IRCSS
Rome, Italy
Mario F. Scaglioni, MD
Department of Hand and Plastic Surgery
Luzerner Kantonsspital
Lucerne, Switzerland;
Zentrum für Plastische Chirurgie
Klinik Pyramide am See
Zurich, Switzerland
Hans Schild, MD
Professor
Department of Radiology
University Hospital Bonn
Bonn, Germany
Katrin Seidenstücker, MD
Specialist in Plastic and Aesthetic Surgery
Head of the Department of Plastic and
Aesthetic Surgery
Sana Hospital Benrath
Düsseldorf, Germany
Andreas Spörlein
Medical Student
Department of Hand, Plastic, and
Reconstructive Surgery, Burn Center
BG Klinik Ludwigshafen
Plastic and Hand Surgery, University of Heidelberg
Ludwigshafen, Germany
Christiane G. Stäuble, MD
Senior Physician
Department of Anesthesiology and Intensive
Care Medicine
Technical University of Munich
Rechts der Isar Hospital
Munich, Germany
Hiroo Suami, MD, PhD
Associate Professor
Australian Lymphoedema Education, Research, and
Treatment (ALERT)
Faculty of Medicine, Health, and Human Sciences
Macquarie University
Sydney, Australia
Nestor Torio, MD
Medical Director
Penna Torio
Clinic for Plastic Surgery
Basel, Switzerland;
Professor of Plastic Surger y
Clinic of Plastic and Hand Surgery
University Medical Center Freiburg
Freiburg, Germany
Chieh-Han Tzou, MD
Professor
Specialist in Plastic, Reconstructive and
Aesthetic Surgery
TZOU Medical
Plastic, Reconstructive and Aesthetic Surgery
Lymphedema and Facial Palsy Center Vienna
Vienna, Austria
Semra Uyulmaz, MD
Senior Physician for Plastic and Hand Surgery
Clinic for Plastic and Hand Surgery
University Hospital Zurich
Zurich, Switzerland
Contributors
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Ellen Vandyck, PT, MSc
Pedagogic Employee in Educational
Development Project Inter-Professional Education
Department of Physiotherapy
Human Physiology and Anatomy (KIMA)
Faculty of Physical Education and
Physiotherapy–Rehabilitation Research Group
Vrije University Brussels;
Assistant Research Chair
Universitair Ziekenhuis Brussel
Medical Oncology Department
Brussels, Belgium
Giuseppe Visconti, MD, PhD
Plastic Surgeon
Department of Plastic and Reconstructive Surgery
Università Cattolica del Sacro Cuore
Fondazione Policlinico Universitario
Agostino Gemelli IRCSS
Rome, Italy
Mikko Visuri, MD
Department of Plastic and General Surgery
Turku University Hospital
Turku, Finland
Stephan Wagner, MD
Senior Physician
Angiology and Angiological Rehabilitation
Rehabklinik
Bad Zurzach, Switzerland
Karl Waked, MD
Plastic, Reconstructive and Aesthetic Surgeon
Department of Plastic and Reconstructive Surgery
Cirumed Clinic
Marbella, Spain;
Founder and CSO
Augmented Anatomy
Knokke, Belgium
Patrick A. Will, MD, MSc
Senior Surgeon
Department of Plastic and Hand Surgery
Center for Orthopedic, Trauma and Plastic surgery
University Hospital Dresden,
Dresden, Germany
Joerg Wilting, MD
Professor
University Medical Center Göttingen
Center of Anatomy
Department for Anatomy and Cell Biology
Göttingen, Germany
Johnson Chia-Shen Yang, MD, PhD, FACS
Director
International Supermicrosurgical
Lymphedema Center;
Associate professor
Plastic and Reconstructive Surgery
Kaohsiung Chang Gung Memorial Hospital
Kaohsiung City, Taiwan
Assaf Zeltzer MD, PhD, FCC(Plast)
Chief of Department Plastic and
Reconstructive Surgery
Rambam Health Care Campus
Haifa, Israel
Joachim E. Zuther, PT, MT, CLT
Founder and Education Director
Academy of Lymphatic Studies
Florida, United States
xxviii
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