Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3783_Библиотеки_им_академика_М_И_Перельмана
.pdf
138
D. Wang and R. Skoracki
https://t.me/medicina_free
Fig. 19.4 Jejunal mesenteric lymph node ap dissected leaving the
posterior leaet of peritoneum intact. Lymph nodes are identied with
a combination of transillumination and palpation
ply to the bowel. Flaps harvested from the periphery of
the mesentery have a better balance of arterial inow and
venous outow as they contain a more physiologic balance of capillary network to blood ow rate as a function
of donor vessel diameter when compared with aps raised
closer to the root where the vascular supply largely
bypasses the nodes. That is why we recommend designing aps from the root of the mesentery as ow-through
aps with two arterial and venous anastomoses each (at
the distal and proximal end of the ap) at the recipient
site.
• The ap is then elevated from the periphery toward the
root of the mesentery, preserving the posterior peritoneal
layer. Leaving this peritoneum intact or repairing any
holes created during dissection prevents an internal
hernia.
• Dissection continues until vessel caliber is adequate for
microvascular anastomosis and pedicle length is as
desired while preserving all major vessels to the jejunum.
Pedicle length is generally 3–5cm. The average size of
the ap is also around 3–5cm (Fig.19.4).
• After ap elevation, the anterior layer of peritoneum is
repaired with a running silk suture as an additional precaution against an internal hernia. The abdominal incisions are then closed in a standard fashion.
Recipient Site Preparation, Flap
Revascularization, andInset
The recipient site is chosen according to the location of the
lymphedema and previous treatment history. It includes scar
removal when applicable from previous lymph node dissection. Our preference is to perform a proximal scar release
and ap placement in cases of Grade 3 (Ohio Scar Scale;
Table 19.1 Ohio Scar Scale – examination and quantication of
lymph node resection scar
Grade Description
0 No scar, no surgical intervention to area
1 Supercial scar, mobile (no tethering, adequate subcutaneous
fat layer)
2 Scar extending into subdermal structures, deep palpable scar,
remains mobile against deeper structures (i.e., chest wall,
groin, fascia/musculature)
3 Visible tethering of skin, scar tethering skin to underlying
deeper structure (i.e., chest wall, deep fascia of the groin),
scar is usually depressed/dimpling
4 Painful tethered scar
19.1), or greater, scarring and the indications are as
Table
outlined below for the upper and the lower extremity [10].
For the upper extremity, the wrist/forearm is chosen if the
lymphedema is more severe in the hand and forearm than
the upper arm. The axilla is chosen if the complete upper
extremity is involved or excess scarring is present in the
axilla. The distal leg is chosen if the patient has had a previous peri-aortic or deep pelvic lymph node dissection and
inguinal nodes are intact. The groin is chosen if there has
been a previous inguinal lymph node dissection and the
patient has signicant thigh swelling. However, if these
proximal sites have a large area of scarring and require more
bulk of vascularized tissue, the omental ap may be a better
option. In these cases, we will consider a dual-level node
transfer with an omental ap placed proximally and a mesenteric ap distally.
Typically, a recipient artery and one vein are prepared
for anastomosis. In the forearm, either the radial or ulnar
artery is used, and in the lower leg, the anterior or posterior
tibial artery is typically preferred. Preoperative vascular
imaging of the lower extremity can be helpful in patients
with primary lymphedema where there may be anatomic
variabilities in the presence and caliber of the vasculature.
If a partial venous outow obstruction is suspected due to
the prior proximal node dissection, a venogram should be
performed preoperatively as venous hypertension will
place the ap at risk.
Following harvest, the ap is then reperfused at the recipient site (Fig.
19.5). The mesenteric vessels closer to the root
can be larger. If the ap was taken at this level, there can be
a mismatch between the arterial inow and the outow possible based on the capillary bed alone. For this reason, we
will inset the ap vessels as a ow-through ap with anastomoses at the distal and proximal ends of the ap artery and
vein either in an end-to-side or end-to-end fashion, or if this
is not an option, we will perform a direct end-to-end anastomosis between distal ap artery and vein to create an arteriovenous (AV) loop and alleviate this problem (Fig.19.5).
Primary skin closure can be achieved if some of the sub-
cutaneous tissue at the recipient site is removed with electro-
ab
19 Step-by-Step Instruction: Jejunal Mesenteric Vascularized Lymph Node Transplant Procedure
https://t.me/medicina_free
c
139
Fig. 19.5 Jejunal mesenteric artery and vein anastomosed to the recip-
ient vessels: (a) arterial anastomosis; (b) venous anastomosis; (c) here,
an arteriovenous (AV) loop has also been performed at the distal ap
cautery. In cases when this would place too much pressure
on the ap, a small full-thickness skin graft harvested adjacent to the laparotomy incision can be placed over the mesenteric lymph node packet (Fig.19.6). This can be excised at
a later date if it is cosmetically displeasing to the patient.
Flap monitoring can be performed percutaneously with a
handheld Doppler over the skin graft or the primarily closed
dermis. We have also successfully used an implantable
Doppler with the piezoelectric crystal removed from the
silastic cuff and inserted directly into the fat of the ap adjacent to the vasculature.
end to optimize the balance between arterial inow and venous outow
for the larger donor vessels included in this ap harvested from the root
of the mesentery
eratively. Antibiotics are prescribed for 1week postoperatively, as patients with lymphedema are at increased risk of
infection to the affected limb.
There are also site-specic considerations. For aps to the
axilla, the arm should be abducted with an abduction pillow
for 1 week postoperatively to avoid ap compression, followed by gradual return to full shoulder range of motion.
The forearm/wrist requires extremity elevation. For the
groin, the patient is instructed to avoid hip exion beyond 45
degrees for 3–4weeks postoperatively. Distally placed aps
in the lower extremity undergo a strict dangle protocol.
Patients resume their compression garments 6–8weeks postoperatively. The patients will see maximal benet at
Postoperative Care
1–2years postoperatively and will be followed in clinic for
physical therapy and measurements for the rest of their lives.
Patients are typically admitted to the hospital to the free ap
oor with the ap monitored with standard Doppler checks.
The orogastric tube is removed during extubation. Diet is
Complications
advanced from clears as tolerated. Occasionally, Reglan may
be prescribed to help bowel motility. We use this commonly
for omental ap harvests to encourage gastric emptying after
manipulation of the greater curvature of the stomach intraop-
A study of 29 patients demonstrated an acceptable complication prole of one ap loss (3.3%), four postoperative hernias (13.8%), and three nonoperative small bowel
140
ab
https://t.me/medicina_free
D. Wang and R. Skoracki
Fig. 19.6 (a) Inset of the ap in the distal extremity. Subcutaneous
tissue can be excised to accommodate the ap, or alternatively a skin
graft can be placed over the ap and later excised. Monitoring can be
obstructions (10.3%) [8]. Patients should also be counseled
about the inherent risks of this approach including incisional
hernias, peritonitis, bowel ischemia, adhesions, and injury to
other abdominal organs.
Pearls and Pitfalls
• The mesenteric lymph node donor site allows for the harvest of multiple packets of lymph nodes from the mesentery and/or the omentum to address multiple recipient
sites if necessary. The donor site can also be used again at
a later time from the original transfer surgery.
• The mesenteric lymph node ap is a good option for heterotopic transfer to the distal extremity due to its small
size and high lymph node density.
• Consider performing a ow-through ap inset or distal AV
loop when the ap is taken more toward the root of the
mesentery to optimize inow and outow balance for a ap
with large (3mm artery and ≥4mm vein) donor vessels
and a relatively small capillary network connecting these.
• For aps harvested from the mesenteric periphery, ensure
preservation of blood ow to the adjacent small bowel by
careful ap location choice and design.
performed either by an implantable Doppler or through percutaneous
Doppler checks. (b) Skin graft is harvested adjacent to the laparotomy
site to avoid an additional scar
2. Liebermann DM, Kaufmann M.Utilization of the greater omentum
in surgery: a historical review. Neth J Surg. 1991;43:136–44.
3. Shimotsuma M, Simpson-Morgan MW, Takahashi T, Hagiwara
A.Activation of omental milky spots and milky spot macrophages
by intraperitoneal administration of a streptococcal preparation,
OK-432. Cancer Res. 1992;52:5400–2.
4. Ruter D, Chen W, Garza R 3rd, Eiferman D, Skoracki
R. Mesoappendix as potential donor site for vascularized lymph
node transfer: anatomic study. J Surg Res. 2018;230:143–7.
5. Coriddi M, Wee C, Meyerson J, Eiferman D, Skoracki
R. Vascularized jejunal mesenteric lymph node transfer: a novel
surgical treatment for extremity lymphedema. J Am Coll Surg.
2017;225:650–7.
6. Schaverien MV, Hofstetter WL, Selber JC. Vascularized jejunal
mesenteric lymph node transfer for lymphedema: a novel approach.
Plast Reconstr Surg. 2018;141:468e–9e.
7. Coriddi M, Skoracki R, Eiferman D. Vascularized jejunal mesenteric lymph node transfer for treatment of extremity lymphedema.
Microsurgery. 2017;37:177–8.
8. Kraft CT, Eiferman D, Jordan S, Skoracki RJ.Complications after
vascularized jejunal mesenteric lymph node transfer: a 3-year experience. Microsurgery. 2019;39:497–501.
9. Chu CK, Schaverien MV, Chang EI, Hanson SE, Hanasono MM,
Selber JC.Intra-abdominal lymph nodes: a privileged donor site for
vascularized lymph node transfer. Plast Reconstr Surg Glob Open.
2020;8:e2673.
10. Coriddi MR, Eiferman DS, Skoracki RJ. Double-level vascularized lymph node transfer for treatment of extremity lymphedema. J
Reconstr Microsurg Open. 2017;2:75–7.
References
1. Nguyen AT, Suami H, Hanasono MM, Womack VA, Wong FC,
Chang EI.Long-term outcomes of the minimally invasive free vascularized omental lymphatic ap for the treatment of lymphedema.
J Surg Oncol. 2017;115:84–9.
Step-by-Step Instruction:
https://t.me/medicina_free
Suction- Assisted Lipectomy Procedure
withControlled Compression Therapy
HåkanBrorson
20
Introduction
Our rst liposuction procedure for lymphedema was undertaken in 1987, but it was not until 1993 that a more detailed
treatment protocol was established for arm lymphedema [1,
2]. Liposuction for leg lymphedema was established 5years
later. Initially, the “dry” technique was used; the introduction of the use of a tourniquet and tumescence has made
liposuction a safe procedure, and there is no longer any
need for blood transfusions [3]. Liposuction is the only
method to completely reduce chronic non-pitting lymphedema. The result is maintained with compression
garments.
Typical Indications
• Primary and secondary upper and lower extremity lymph-
edema with a limb excess volume of 10% or greater
• Minimal pitting: 4–5mm in arms and 5–6mm in legs
• No active cancer
• No further improvement with conservative treatment
• No active wounds
• No age limit
Supplementary Information The online version of this chapter
(https://doi.org/10.1007/978-3-030-93039-4_20) contains supplementary material, which is available to authorized users.
H. Brorson (*)
Lymphedema Center, Plastic and Reconstructive Surgery, Skåne
University Hospital, Malmö, Sweden
Department of Clinical Sciences, Malmö, Lund University, Lund,
Sweden
e-mail: hakan.brorson@med.lu.se
Excess Subcutaneous Adiposity andChronic
Lymphedema
Liposuction in the only method to completely reduce nonpitting chronic lymphedema where the excess volume is
dominated by adipose tissue [4–6]. The incidence of postmastectomy arm lymphedema varies between 13% and 52%,
depending in part on whether axillary lymph nodes have
been removed and postoperative radiation has been given [7,
8]. The sentinel node technique had decreased the incidence
of postoperative lymphedema to an estimated incidence of
approximately 6–8% [9]. Risk-reducing surgery using immediate lymphatic reconstruction shows an incidence of lymphedema of 9.1% at short-term follow-up [10].
The outcome of the surgical procedure as well as the radiation to the tissues often results in destruction of lymphatic
vessels. When this is combined with the removal of lymph
nodes and tissue scarring, the lymphatic vessels that remain
are likely to be unable to remove the lymph uid load. The
remaining lymph collectors become dilated and overloaded,
and their valves become incompetent, preventing the lymphatics from performing their function. This failure spreads
distally until even the most peripheral lymph vessels, draining into the affected system, also become dilated [11]. In a
parallel process, the cells of the mononuclear phagocytic
system of the mesenchymal tissues begin to lose their capability to remove the protein that accumulates. The accumulated interstitial proteins, as osmotically active molecules,
attract uid to the area. This accumulation of protein and
uid is usually a transient phase, lasting between 1 and
3weeks [11].
In the latent phase, there may still initially be no clinical
signs of any discernible lymphedema. The latent phase normally varies from about 4months to 10years. At the end of
the latent phase, pitting of the edematous limb on pressure
can be observed. This can be objectively measured by plethysmography and by decreased tissue compressibility using a
tissue tonometer [11, 12].
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
M. V. Schaverien, J. H. Dayan (eds.), Multimodal Management of Upper and Lower Extremity Lymphedema,
https://doi.org/10.1007/978-3-030-93039-4_20
141
142
Excess volume reduction (mean SEM)
Time
Excess volume (ml)
https://t.me/medicina_free
H. Brorson
The enlargement of the extremity leads to discomfort and
complaints in the form of heaviness, weakness, pain, tension,
and sensory decit of the limb, as well as anxiety, psychological morbidity, maladjustment and social isolation, and
increasing hardness of the limb [13, 14]. Adipose tissue
deposition already starts within the rst year after lymphedema onset [15–18]. In time, there is also an increase in the
adipose tissue content of the swollen limb. The author has
observed this clinically since 1987, when the rst lymphedema patient was operated on [1, 2]. This phenomenon led
to further research, as presented in this chapter [15–19].
There are various possible explanations for the adipose tissue hypertrophy. There is a physiological imbalance of blood
ow and lymphatic drainage, resulting in the impaired clearance of lipids and their uptake by macrophages [20, 21]. There
is increasing support, however, for the view that the fat cell is
not simply a container of fat, but it behaves like an endocrine
organ and a cytokine-activated cell [22, 23], and chronic
inammation plays a role here [24, 25]. The same pathophysiology goes for primary and secondary lymphedema. For more
detailed information about investigational advances and the
relationship between slow lymph ow and adiposity, as well
as that between structural changes in the lymphatic system and
adiposity, see data from studies published by Harvey etal. [26]
and Schneider etal. [27], as well as other studies with contributory evidence [6, 12, 15, 16, 24, 28–33].
A common misunderstanding among clinicians is that the
swelling of a lymphedematous extremity, whether it is primary
or secondary, is due purely to the accumulation of lymph and/or
brosis. In one study, preoperative investigation with volumerendered computed tomography (CT) images showed a signicant preoperative increase of adipose tissue in the swollen arm,
the excess volume consisting of 81% (range, 68–96%) fat [15].
In another study, analyses with dual x-ray absorptiometry
(DXA) that were compared to plethysmography in 18 women
with arm lymphedema following mastectomy showed a signicant increase of adipose tissue, 73% (range, 43–111%), in the
non-pitting swollen arm before surgery [16]. Consecutive analyses of the content of the aspirate removed under bloodless conditions using a tourniquet showed a very high content of adipose
tissue in 105 women with postmastectomy arm lymphedema
(mean, 94%; range, 58–100%) [6]. Lymph can be removed by
the use of noninvasive conservative regimens such as complex
decongestive therapy (CDT) and controlled compression therapy (CCT). These therapies work well when the excess swelling
consists of accumulated lymph but do not work when the excess
volume is dominated by adipose tissue [1, 2, 15–19, 34]. The
same may go for microsurgical procedures using lymphovenous
shunts [35, 36], lymph vessel transplantation [37, 38], and vascularized lymph node transfer [39].
How toAssess theEcacy ofLiposuction
Today, chronic non-pitting arm lymphedema of more than
4L in excess can be effectively removed by the use of liposuction without any further reduction in lymph transport.
Long-term results have not shown any recurrence of the arm
swelling (Figs.20.1 and 20.2) [1, 2, 5, 6]. Promising results
can also be achieved for primary and secondary leg lymphedema, where over 6L in excess volume can be completely
reduced (Figs.20.3, 20.4, and 20.5) [4, 40].
Preoperative Planning forArm Liposuction
Made-to-measure compression garments (three sleeves and
two gloves) are ordered 2weeks before surgery. One garment, to be put on the arm at the time of surgery, is sterilized
and used for only 2days since it loses some of its pressure
a
b
Fig. 20.1 (a) A 74-year-old woman with non-pitting arm lymphedema
for 15years. Preoperative excess volume was 3090mL. (b) Postoperative
result
Fig. 20.2 Mean
postoperative excess volume
reduction in 95 women with
arm lymphedema following
breast cancer [52]
2000
1500
1000
500
0
–500
Preop. 2 w1 m3 m6 m1 y2 y3 y4 y5 y
6 y7 y8 y9 y 10 y 11 y 12 y 13 y
20 Step-by-Step Instruction: Suction-Assisted Lipectomy Procedure withControlled Compression Therapy
https://t.me/medicina_free
Fig. 20.3 Preoperative
excess volume 5380mL
(left). Postoperative result
after 3years where excess
volume is -255mL, i.e., the
treated leg is somewhat
smaller than the normal one
(right)
143
Fig. 20.4 Preoperative
excess volume 6630mL
(left). Postoperative result
after 2years with complete
reduction (right)
144
https://t.me/medicina_free
H. Brorson
Fig. 20.5 Primary lymphedema, excess volume 4940mL before liposuction (left). After liposuction up to the tourniquet (right)
by sterilization. The size of the garments is measured
according to the size of the unaffected arm and hand. We
always have standard interim gloves and gauntlets (a glove
without ngers but with a thumb) in stock, used as described
later. One interim glove is sterilized to be put on at the time
of surgery. Liposuction is executed circumferentially, step
by step, from hand to shoulder, and the hypertrophied fat is
removed as much as possible (Figs.20.6, 20.7, 20.8, and
20.9).
Operative Technique (see supplementary
material)
For the majority of patients, power-assisted liposuction
(Lipomatic, Nutational Infrasonic Liposculpture, Euromi,
Andrimont, Belgium) is performed to facilitate liposuction.
Around ten 3- to 4-mm-long incisions are made, and liposuc-
tion is performed using 15- and 25-cm-long cannulas with
diameters of 3 and 4mm. Initially, the hand was also treated,
but since no fat could be aspirated, we ceased to treat this
area. Circumferential liposuction is performed from wrist to
shoulder and as much of the hypertrophied fat is removed as
possible using previously measured circumferences of the
healthy arm as a control (Figs.20.6, 20.7, and 20.8). When
the arm distal to the tourniquet has been treated, a sterilized
custom-made compression sleeve is applied (Jobst Elvarex,
compression class 2) to the arm to minimize bleeding and
reduce postoperative edema. A sterilized, standard interim
glove (Cicatrex interim, Thuasne Begat, France) is put on the
hand. The tourniquet is then removed, and the most proximal
part of the upper arm is treated using the tumescent technique, where 1000ml saline is mixed with 1mg adrenaline
and 40ml lidocaine 2% [1–3, 5, 6]. The technique for legs
(Figs. 20.3, 20.4, and 20.5) is similar to that for arms
(Figs.20.6, 20.7, and 20.8).
20 Step-by-Step Instruction: Suction-Assisted Lipectomy Procedure withControlled Compression Therapy
https://t.me/medicina_free
145
Fig. 20.6 Liposuction of arm lymphedema. The procedure takes about 2hours. From preoperative to postoperative state (left to right). Note the
tourniquet, which has been removed on the right, and the concomitant reactive hyperemia
a b
Fig. 20.7 (a) Preoperative picture showing a patient with a large right
lymphedematous arm (2865mL excess volume) with decreased mobility; (b) the cannula lifts the loose skin of the treated forearm (left); the
distal half of the forearm has been treated – note the sharp border
between treated (distal forearm) and untreated (proximal arm) areas
(right)
146
https://t.me/medicina_free
H. Brorson
Postoperative Care
Two days postoperatively, the garments are removed by the
patient under supervision so that the patient can take a
shower. The arm is lubricated with lotion. Then, the other set
of garments are put on, and the used set is washed and dried.
Change of garments is repeated by the patient after another
2 days before hospital discharge. The standard glove and
gauntlet are usually changed to the made-to-measure glove
at the end of the stay.
The patient alternates between the two sets of garments
(two sleeves and two gloves) during the rst week at home,
changing them every other day so that a clean set is always
put on after showering and lubricating the arm. Then garments are changed daily. Washing “activates” the garment by
increasing the compression due to shrinkage. It also removes
products of perspiration that can cause dry and irritated skin.
During the subsequent course, this rigorous compression
regime, referred to as CCT, is maintained exactly as described
in the next section.
Fig. 20.8 The aspirate contains 90–100% adipose tissue in general.
This picture shows typical aspirates collected from a lymphedematous
arm before removal of the tourniquet. The aspirate to the left sediments
into an upper adipose fraction (90%) and a lower uid (lymph) fraction
(10%). To the right, no uid fraction is seen
Fig. 20.9 The compression garment is removed 2days after surgery to
take measurements for a custom-made compression garment. A signicant reduction of the right arm has been achieved, as compared with the
preoperative condition seen in Fig.20.7a
Complications
So far, no major complications have occurred. Skin numbness is normal after liposuction and disappears after a couple
of weeks. No skin necrosis has occurred.
Controlled Compression Therapy (CCT)
A prerequisite to maintaining the effect of liposuction, and,
for that matter, conservative treatment, is the lifelong, continuous (24h/day) use of a compression garment [1, 2, 5, 6].
If the patient has any doubts about continued CCT, the
patient is not accepted for treatment.
After initiating compression therapy, the custom-made
garment may be taken in at each visit using a sewing machine
to compensate for reduced elasticity and reduced arm volume. This is most important during the rst 3months when
the most notable changes in volume occur. At the 1- and
3-month visits, the arm is measured for new custom-made
garments. This procedure is repeated at 6, 9, and 12months.
If complete reduction has been achieved at 6months, the
9-month control may be omitted. If this is the case, it is
important to remember to prescribe garments for 6months.
When the excess volume has decreased as much as possible and a steady state is achieved, new garments can be
prescribed using the latest measurements. In this way, the
garments (two sets of sleeve and glove garments) are renewed
three or four times during the rst year. The patient is
informed about the importance of hygiene (daily shower
with soap and water) and skin care (moisturizing the skin
with lotion), as all patients with lymphedema are susceptible
to infections [1, 2, 5, 6].
20 Step-by-Step Instruction: Suction-Assisted Lipectomy Procedure withControlled Compression Therapy
https://t.me/medicina_free
147
The lifespan of two garments worn alternately is usually
3–6months. After complete reduction has been achieved, the
patient is seen once a year when new garments are prescribed
for the coming year, usually four garments and four gloves
(or four gauntlets). In active patients, six to eight garments
and the same amount of gauntlets/gloves a year are needed.
For legs, it is often necessary to use up to two to three
compression garments on top of each other, depending on
what is needed to keep pitting away. The larger the diameter
of the leg, the more compression is needed according to the
law of Laplace. A typical example is Elvarex compression
class 3, Elvarex compression class 2, and, when needed, Jobst
Bellavar compression class 2. The Elvarex class 2 garment
can be a leg-length or a below-the-knee garment. During
night only one layer is used. Thus, such a patient needs two
sets of two to three garments. It is important to take loose
measurements at the ankle since the diameter here is small,
giving more compression than needed. An alternative is to
order a leg-length garment without the foot part of one of the
garments. The follow-up regimen is the same as for arms.
CCT can also be used primarily to effectively treat pitting
edema as an alternative to CDT, which, in contrast to CCT,
comprises daily interventions [1, 2].
patient compliance or worn-out garments. Also, one visit a
year is economical as compared to conservative treatment,
where patients are prescribed massage once a week and
repeated maintenance therapies lasting 1–2weeks.
How Liposuction Helps
For many patients, conservative treatment does not work
well or meet their expectations, and no matter what therapy
they receive, neither conservative treatment nor microsurgical procedures can remove excess adipose tissue [34–39].
Subcutaneous tissue debulking is the only option to completely reduce the limb excess volume leading to an improvement in the patient’s quality of life [13, 14]. In addition, data
from a prospective study that evaluated 130 patients with
postmastectomy lymphedema treated with liposuction
showed that the incidence of erysipelas was reduced by 87%
[41]. The mean incidence of pre-liposuction and postliposuction erysipelas episodes was 0.47 attacks/year (±0.8)
and 0.06 attacks/year (±0.3), respectively.
Lymph Transport System andLiposuction
Volume Measurements
Volumes are recorded for each patient using the water displacement technique. The displaced water is weighed on a
balance to the nearest 5 g, corresponding to 5 mL. Both
extremities are always measured at each visit, and the difference in volumes is designated as the edema volume, or more
correctly the excess volume. The decrease in the excess volume is calculated in a percentage of the preoperative value
[1, 2, 5, 6].
Lymphedema Team
To investigate and treat patients with lymphedema, a team
comprising a plastic surgeon, an occupational therapist, and
a physiotherapist is needed. An hour is reserved for each
scheduled visit to the team when limb volumes are measured, garments are adjusted or renewed, social circumstances are assessed, and other matters of concern are
discussed. The patient is also encouraged to contact the team
whenever any unexpected problems arise so that these can be
tackled without delay. The team also monitors the long-term
outcome, and a visit once a year is necessary, in most cases,
to maintain a good functional and cosmetic result after complete reduction.
This regimen omits any repeated “maintenance treatment,” since if the excess volume increases, it indicates less
To investigate the effect of liposuction on lymph transport,
the author conducted an investigation using indirect lymphoscintigraphy in 20 patients with postmastectomy arm lymphedema. Lymphoscintigraphy was performed before
liposuction, with and without wearing a garment. This was
repeated after 3 and 12months. In conclusion, it was found
that the already decreased lymph transport was not further
reduced after liposuction [42]. Eleven of our patients (6%)
with arm lymphedema do not wear any compression. A
recent study has shown that liposuction for lymphedema can
improve lymph transport [43].
When toUse Liposuction toTreat
Lymphedema
A surgical approach, with the intention of removing the
hypertrophied adipose tissue, seems logical when
conservative treatment has not achieved satisfactory excess
volume reduction and the patient has subjective discomfort
of a heavy arm.
Initially, lymphedema starts as a swelling that shows pits
on pressure. If treated immediately by conservative regimens, the swelling can disappear. If not, or improperly
treated, the swelling increases over time and can end up with
even more severe pitting edema with concomitant adipose
tissue formation. The rst and most important goal is to
transform a limb with pitting edema into a non-pitting one by
Соседние файлы в папке Библиотека им академика М.И. Перельмана