Lymphedematous Limbs Research Articles

Measurement Issues in Anthropometric Measures of Limb Volume Change in Persons at Risk for and Living with Lymphedema: A Reliability Study.

Understanding whether a true change has occurred during the process of care is of utmost importance in lymphedema management secondary to cancer treatments. Decisions about when to order a garment, start an exercise program, and begin or end therapy are based primarily on measurements of limb volume, based on circumferences taken by physiotherapists using a flexible tape. This study aimed to assess intra-rater and inter-rater reliability of measurements taken by physiotherapists of legs and arms with and without lymphedema and to evaluate whether there is a difference in reliability when measuring a healthy versus a lymphedematous limb. The intra-rater reliability of arm and leg measurements by trained physiotherapist were very high (scaled standard error of measurements (SEMs) for an arm and a leg volume were 0.82% and 0.64%, respectively) and a cut-point of 1% scaled SEM may be recommended as a threshold for acceptable reliability. Physiotherapists can rely on the same error when assessing lymphedematous or healthy limbs. For those who work in teams and share patients, practice is needed in synchronizing the measurements and regularly monitoring their inter-rater reliability.

Referral patterns to a surgical lymphoedema service: 10 years of experience

Liposuction for lymphoedematous limbs is an effective treatment for chronic lymphoedema, with excellent long-term results in well-selected patients. In 2008 NICE produced guidelines 'Liposuction for Chronic lymphoedema', acknowledging this treatment modality. However, there remain very few centers that provide this service in the United Kingdom. We aim to share our experience of our referral system at Ninewells Hospital, Dundee, Scotland. A 10 year prospective database from 2005 to 2014 was analysed. Referral sources, patient demographics, diagnosis and treatment offered were examined. There were 221 referrals in total, 190 (86%) female and 31 (14%) male. The mean age was 51 (range 7-86 years). 127 (58%) were referred via their general practitioners, 72 (33%) from a hospital consultant and 22 (10%) from a lymphoedema nurse specialist. 153 (69%) referrals were from Scotland, 61 (28%) from England and 7 (3%) from Northern Ireland. The majority of patients 165 (75%) were referred with lower limb swelling. Following assessment in clinic, 146 (66%) were found to have lymphoedema whilst the rest were deemed to have other non-lymphoedematous diagnoses which include lipoedema (47, 21%), dependent oedema (8, 4%) and obesity (5, 2%). 131 (59%) were offered liposuction- 74 (34%) have received liposuction, 18 (8%) are awaiting their procedure, 3 (1%) have declined surgery, 27 (12%) are awaiting funding approval and 9 (4%) have been declined funding by their primary care trust/clinical commissioning group (PCT/CCG). 4 (2%) are awaiting investigations to further evaluate the cause of their swelling, whilst the remaining 86 (39%) were felt unsuitable for surgery and were treated conservatively. Chronic lymphoedema is a challenging condition to treat, with few specialist centers offering surgical treatment. We hereby share our referral process, diagnosis and management.

Lymphaticovenous Bypass Decreases Pathologic Skin Changes in Upper Extremity Breast Cancer-Related Lymphedema

Recent advances in microsurgery such as lymphaticovenous bypass (LVB) have been shown to decrease limb volumes and improve subjective symptoms in patients with lymphedema. However, to date, it remains unknown if these procedures can reverse the pathological tissue changes associated with lymphedema. Therefore, the purpose of this study was to analyze skin tissue changes in patients before and after LVB. Matched skin biopsy samples were collected from normal and lymphedematous limbs of 6 patients with unilateral breast cancer-related upper extremity lymphedema before and 6 months after LVB. Biopsy specimens were fixed and analyzed for inflammation, fibrosis, hyperkeratosis, and lymphangiogenesis. Six months following LVB, 83% of patients had symptomatic improvement in their lymphedema. Histological analysis at this time demonstrated a significant decrease in tissue CD4(+) cell inflammation in lymphedematous limb (but not normal limb) biopsies (p<0.01). These changes were associated with significantly decreased tissue fibrosis as demonstrated by decreased collagen type I deposition and TGF-β1 expression (all p<0.01). In addition, we found a significant decrease in epidermal thickness, decreased numbers of proliferating basal keratinocytes, and decreased number of LYVE-1(+) lymphatic vessels in lymphedematous limbs after LVB. We have shown, for the first time, that microsurgical LVB not only improves symptomatology of lymphedema but also helps to improve pathologic changes in the skin. These findings suggest that the some of the pathologic changes of lymphedema are reversible and may be related to lymphatic fluid stasis.

Lymphedema fat graft: an ideal filler for facial rejuvenation.

Lymphedema is a chronic disorder characterized by lymph stasis in the subcutaneous tissue. Lymphatic fluid contains several components including hyaluronic acid and has many important properties. Over the past few years, significant research has been performed to identify an ideal tissue to implant as a filler. Because of its unique composition, fat harvested from the lymphedema tissue is an interesting topic for investigation and has significant potential for application as a filler, particularly in facial rejuvenation. Over a 36-month period, we treated and assessed 8 patients with lymphedematous limbs who concurrently underwent facial rejuvenation with lymphedema fat (LF). We conducted a pre- and post-operative satisfaction questionnaire survey and a histological assessment of the harvested LF fat. The overall mean general appearance score at an average of 6 months after the procedure was 7.2±0.5, demonstrating great improvement. Patients reported significant improvement in their skin texture with a reading of 8.5±0.7 and an improvement in their self-esteem. This study demonstrates that LF as an ideal autologous injectable filler is clinically applicable and easily available in patients with lymphedema. We recommend the further study and clinical use of this tissue as it exhibits important properties and qualities for future applications and research.

Alterations of skin innate immunity in lymphedematous limbs: Correlations with opportunistic diseases

Lymphedematous areas are sites of regional immune destabilization depicting a typical example of an immunocompromised cutaneous district (ICD). This study evaluates the expression of some components of the skin innate immunity on lymphedematous limbs with the aim to clarify some facets of the ICD. Patients selected underwent two skin biopsies: One was obtained from the limb affected by lymphedema, another from the contralateral healthy limb. Expression of some components of the skin innate immunity was analyzed by reverse transcription–polymerase chain reaction.Stronger gene expression of Toll-like receptor 2 (TLR-2), human β-defensin 2 (HBD-2), desmoglein 1, desmoglein 3, matrix metallopeptidase 9 (MMP-9), and interleukin 10 (IL-10) was found in keratinocytes derived from the affected limb compared with that of keratinocytes derived from contralateral healthy limb. Downregulation of survivin and vasoactive intestinal polypeptide (VIP) gene expression was found in the affected limbs. No induction of IL-1α and tumor necrosis factor α (TNF-α) was detectable in keratinocyte cultures obtained from both lymphedematous and normal limbs.Different phases and components of skin innate immunity turned out to be altered in the lymphedematous sites. Molecular alterations were similar in all patients recruited in the study. These changes might favor the local appearance or progression of opportunistic diseases such as tumors, infections, and immune-mediated skin disorders.

Sequential Anastomosis for Lymphatic Supermicrosurgery

Supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming a treatment option for progressive lymphedema. Various types of LVA such as end-to-end, end-to-side, side-to-end, and side-to-side are performed to improve the treatment efficacy. We applied sequential anastomosis for LVA surgery, in which 2 lymphatic vessels were anastomosed to 1 venule using side-to-side and side-to-end anastomoses. Six lower extremity lymphedema (LEL) patients who underwent sequential anastomosis were included in this study. Feasibility, anastomosis patency, and treatment effect of the method were evaluated. Six sequential anastomoses were performed on 6 lymphedematous limbs. All sequential anastomoses showed good anastomosis patency after completion of anastomoses. A significant decrease in LEL index was seen postoperatively (244.0 ± 14.6; postoperative LEL index vs 263.5 ± 19.4; preoperative LEL index, P = 0.002). Sequential anastomosis can divert both normograde and retrograde lymph flows from 2 lymphatic vessels into 1 venule. Sequential LVA is a useful method to increase lymph flow bypasses, when there are fewer venules than lymphatic vessels.

Bioelectrical Impedance Self-Measurement Protocol Development and Daily Variation Between Healthy Volunteers and Breast Cancer Survivors with Lymphedema

A significant percentage of breast cancer survivors are at risk for lymphedema for which lifelong self-care is required. Previous studies suggest that less than 50% of breast cancer survivors with lymphedema (BCS-LE) perform prescribed self-care tasks and that even wearing a compression sleeve, the most commonly reported self-care activity, is done irregularly. Reasons for poor self-care adherence include perceived lack of results from self-care (no available arm volume data) and perceived inability to manage the condition. A two-part pilot study was conducted to: 1) develop and determine the feasibility of a self-measurement protocol using a single frequency bioelectrical impedance device; and 2) examine daily variation in extracellular volume in healthy and lymphedematous limbs. Healthy and BCS-LE volunteers were recruited to refine and test a self-measurement protocol. Volunteers were trained in the use of the device and measured for 5 consecutive days in a laboratory setting. They were then given the device to use at home for an additional 5 consecutive days of self-measurement. All volunteers completed each scheduled home measurement. Daily variability in both groups was noted. Home self-measurement using bioelectrical impedance is feasible, acceptable, and captures change. This has implications for both self-care support and for the possibility of incorporating self-measurement using bioelectrical impedance in future clinical trials examining effectiveness of lymphedema treatment.

Synergistic effect of adjustments of elastic stockings to maintain reduction in leg volume after mechanical lymph drainage.

The objective of the present study was to evaluate the effect of elastic compression stockings on volumetric variations of lymphedematous limbs between mechanical lymph drainage sessions. Eleven patients with Grade II leg lymphedema, regardless of etiology, were evaluated in a randomized clinical trial. The ages ranged from 47 to 83 years old with a mean of 62.4 years. Participants were submitted to mechanical lymph drainage (RAGodoy) associated with adjusted and unadjusted knee-high elastic compression stockings (20/30 Venosan). The effect of these stockings on the maintenance of volumetric reductions between sessions of lymph drainage was assessed. In all, 33 evaluations were carried out, 18 of patients using well-adjusted stockings and 15 with badly-adjusted stockings. The differences in volumes were significant (unpaired t-test; P-value < 0.0001). Adjusting the compression provided by elastic stockings according to the size of the leg has a synergistic effect in reducing volume during mechanical lymph drainage.

Pressures and Timing of Intermittent Pneumatic Compression Devices for Efficient Tissue Fluid and Lymph Flow in Limbs with Lymphedema

Pneumatic compression of tissues with lymph stasis is, aside from the manual massage, a commonly used therapeutic modality in limb lymphedema. A number of pneumatic devices have been constructed. There is lack of reports of comparative studies determining inflation pressure levels, inflation/deflation cycle times, and total pumping times. We tried to answer the question how high compression pressure and how long compression timing should be applied to the limb soft tissues to reach tissue fluid (TF) head pressure above 30 mmHg, necessary to initiate proximal flow. TF pressures were measured subcutaneously during intermittent pneumatic compression in the lymphedematous limbs stage II to IV. Pressures of 50, 80, and 120 mmHg and timing 5, 20, and 50 sec were applied. a) the TF head pressures were lower than those in inflated chambers, b) inflation time of 5 and 20 sec was not long enough to generate TF head pressures above 30 mmHg, even if the compression pressures were as high as 120 mmHg, c) the 50 sec timing allowed to reach head pressures above 30 mmHg; however, they remained always lower than in the compression chamber, d) TF head pressures differed at various levels of the limb depending on the soft tissue mass, e) deflation of the inflated whole sleeve for 5 and 20 sec was followed by high end pressures, whereas that of 50 sec brought about pressure drop to 0, facilitating refilling with TF of the distal parts of the massaged limb. Our observations point to the necessity of applying high pressures and compression times over 50 sec, to generate effective TF pressures and provide enough time for creating TF flow. Short inflation times generate TF pressures as in one-chamber devices that preclude its effectiveness compared to the multi-chamber devices.

Primary upper-limb lymphoedema

Lymphoedema is a general term used to designate pathological, regional accumulation of protein-rich fluid. It can be either primary or secondary, and mainly occurs after cancer treatment. To analyse the clinical and lymphoscintigraphic characteristics of primary upper-limb lymphoedema (ULL). All of the patients with ULL were recruited at a single Department of Lymphology between January 2007 and December 2011. In total, 60 patients (33 female, 27 male) were enrolled. For the 54 noncongenital lymphoedemas, the mean age at onset was 38·5 (range 3-82) years. Lymphoedema was unilateral in 51 patients (85%). It always affected the hand, and less often the forearm (55%) or upper arm (23%). Eleven patients (18%) developed cellulitis after onset of lymphoedema, and 21 patients (35%) had associated lower-limb lymphoedema (LLL). Forty-six patients (with 49 lymphoedematous limbs) underwent lymphoscintigraphy: axillary lymph node uptake was diminished in 18 (37%), absent in 24 (49%) and normal in seven limbs (14%). Among the 43 patients with unilateral lymphoedema and lymphoscintigraphy, 28 had epitrochlear node visualization, suggesting a rerouting through the deep lymphatic system, with 15 only on the lymphoedematous limb and 22 on the contralateral nonlymphoedematous limb. The median follow-up period was 103 months, and 57/60 patients (95%) considered their lymphoedema to be stable. Primary ULL appears later in life than LLL, without predominance in either sex. Infectious complications are rare and patients considered the lymphoedema volume stable throughout life.

Decongestion improves cell‐mediated immunity in postmastectomy arm lymphoedema: a pilot study

Chronic lymphoedematous limbs have an increased propensity for infections and primary or secondary malignant tumours. It has been attributed to suppressed delayed-type hypersensitivity measured in lymphoedemas related to Stewart-Treves syndrome, Kaposi's sarcoma or breast cancer treatment. Cell-mediated immunity is an effective defence mechanism against bacteria, fungi, viruses and tumour cells. We aimed to examine whether decongestive lymphoedema therapy could improve cell-mediated immunity in breast cancer treatment-related lymphoedema (BCRL). Eight women with unilateral BCRL were included in this study. At baseline, tuberculin skin test (TST) was performed on the volar surfaces of the forearms of the affected and non-affected sides using 0.5, 1 and 5 tuberculin units in the form of three consecutive injections with 3-cm spaces in-between, and arm volumes were measured using the Kuhnke's disc model. Decongestive lymphatic therapy was given to swollen arms in 10 consecutive working days. At the end of intensive decongestion, TST on affected side and bilateral volumetry were repeated. Baseline test using undiluted (5 units) and fivefold diluted (1 unit) tuberculin solutions has shown significant differences (P < 0.05) between the mean sizes (11.81 ± 2.32 and 7.75 ± 1.92; 7.12 ± 1.12 and 5.12 ± 0.91 respectively) in favour to healthy arms. Post therapeutically, the mean sizes were significantly increased (P < 0.05) in the dilutions of 1 : 1 and 1 : 5 (7.75 ± 1.92 and 10.56 ± 1.23 mm, 5.12 ± 0.91 and 5.93 ± 1.74 mm respectively). Significant increase in TST sizes suggests that decongestive lymphatic therapy is able to partially restore impaired cellular immune function in BCRL.

Management of ulcers in lymphoedematous limbs

Lymphoedema is a progressive condition that can have a marked physical and psychological impact on affected patients and significantly reduce the quality of life. The ulcers on chronic lymphoedema patient, which often also makes it impossible for them to work. If left untreated, tends to progress or worsen. Ulcers in lymphoedema patients, therefore, represent not only a medical but also a psychological problem. The treatment is often regarded as being worse than it actually is. In our study of more than 25 years shows around 10% cases are due to chronic lymphodema. Ulcers of chronic lymphoedema are classified into four stages according to their presentation. Their management depends upon their stage of presentation. Patients with chronic lymphoedema and ulceration require a different approach to treatment. The specific issues associated with managing the patient with lymphoedematous ulceration include, limb shape distortion i.e., elephantiasis, care of the skin creases and folds, and swelling of the toes and fore foot. Stage I ulcers will heal with conservative treatment without any surgical intervention. Stage II ulcers needs debridement of the wound and split-thickness skin grafting. The most difficult to treat are the stage III and IV ulcers, due to associated skin changes and reduced vascularity. These cases need debulking along with excision of the ulcer. In order to prevent recurrence of the ulcer in all the four stages needs prolonged follow-up and limb care.

Lymphatic valve lock in response to modest gravitational loads: a contributing mechanism to peripheral lymphedema?

Lymphedematous limbs often have an uninterrupted column of lymph that implies an underlying contractile dysfunction of collecting lymphatic vessels. To test this idea, single lymphangions were isolated, cannulated and connected to a servo system to control input (Pin) and output (Pout) pressures. Intraluminal pressure was measured with vessel diameter and valve position. As Pout and Pin were slowly raised in parallel, with Pout &gt; Pin to mimic conditions in a dependent extremity during development of edema, the vessel progressively distended and the output valve would appear to suddenly “lock” into the open position. Valve lock appeared to result from the interaction of three factors: tone, pump strength, and valve leaflet stiffness. In multiple lymphangion segments, valve lock occurred in the weakest lymphangion and progressed to its neighbors as pressure rose. Surprisingly, valve lock was reversible if tone was enhanced using a contractile agonist, even at elevated Pout levels. We propose that pump strength, valve leaflet stiffness and tone normally interact to minimize the likelihood of valve lock, which reflects an inherent susceptibility of the valves that can be triggered by modest pressure or volume overload. Once valve lock occurs, it would exacerbate edema by creating an uninterrupted lymph column that transmits a pathological pressure level back to the lymphatic capillaries.

Tissue Fluid Pressure and Flow during Pneumatic Compression in Lymphedema of Lower Limbs

Physiotherapy of edema in cases with obstructed main lymphatics of lower limbs requires knowledge of how high external pressures should be applied manually or set in compression devices in order to generate tissue pressures high enough to move tissue fluid to nonswollen regions and to measure its flow rate. We measured tissue fluid pressure and flow in subcutaneous tissue of lymphedematous limbs stages II to IV at rest and during pneumatic compression under various pressures and inflation timing. An 8-chamber sequential compression device inflated to pressures 50-120 mmHg, for 50 sec each chamber, with no distal deflation, was used. Pressures were measured using a wick-in-needle and electronic manometer. Fluid flow was calculated from continuously recorded changes in limb circumference using strain gauge plethysmography. Before massage, in all stages of lymphedema, stagnant tissue fluid pressures in subcutaneous tissue ranged between -1 and +10 mmHg and did not differ from those measured in normal subjects. Pressures generated in tissue fluid by pneumatic compression reached 40-100 mmHg and were lower than those in inflated chambers. High pressure gradient through the skin was caused by its rigidity (fibrosis) and dissipation of applied compression force to proximal noncompressed limb regions. The calculated volumes of displaced tissue fluid ranged from 10 to 30 ml per compression cycle, to reach in some cases 100 ml in the groin region. Tissue fluid pressures generated by a pneumatic device were found lower than in the compression chambers. The obtained results point to the necessity of applying high pressures and longer compression times to generate effective tissue fluid pressures and to provide enough time for moving the stagnant fluid.

Evaluation of lymph drainage using bioelectrical impedance of the body

The aim of this study was to investigate the effects of manual and mechanical lymph drainage on the bioelectrical composition of body tissues of patients with lymphoedema of the lower limbs. Twenty-one patients with lymphoedema of one leg were evaluated using single frequency bioelectrical impedance with four electrodes (SF-BIA4) immediately before and after a combination of manual and mechanical lymph drainage. Statistical analysis used the two-tailed paired t-test with an alpha error of 5% being considered acceptable. On comparing the results before and after lymph drainage, statistically significant differences were identified for both lymphoedematous and apparently healthy legs, but there were no significant differences in the alterations caused by the treatment between the healthy and lymphoedematous limbs of the same patient. It was concluded that the association of manual and mechanical lymph drainage both modified the body composition as identified by bioelectrical impedance, and reduced the oedema.

Integrating modern dermatology and Ayurveda in the treatment of vitiligo and lymphedema in India

Globally, governments have recognized the growing popularity of Complementary and Alternative Medicines and the possibility of their combined use with biomedicine. Decisions within the Government of India have led to a conducive environment for conducting clinical studies, to achieve integration of more than one system of medicine, so that their combined benefits can be brought to bear on chronic, difficult-to-treat conditions. To develop integrative dermatology treatment protocols for patients with long-standing skin diseases who have received treatment from many centers. A team of doctors from modern dermatology, Ayurveda, yoga therapy, and homeopathy studied recruited patients to develop mutual orientation on each therapeutic system and a working knowledge of approach to their clinical diagnosis. Six-hundred thirty-eight patients affected by lower limb lymphedema requiring skin care as a major part of treatment were treated integrating modern dermatology and Ayurveda. Three-hundred eighty-one vitiligo patients were examined and treated to understand the clinical presentations and treatment options in Ayurveda. A two-step cluster analysis performed by SPSS Version 16 showed average volume reductions of 13.3% and 23% on day 14, 19.7% and 31.1% on day 45, and 23.4% and 39.7% on day 90 of treatment in small and large lymphedematous limbs. Inflammatory episodes before the onset on this treatment was reported by 79.5% of our lymphedema patients, and 9.4% reported this at the end of three months after our treatment. Among vitiligo patients, we found that 39.6% of patients had kapha, 39.8% pitta, 10.8% had vatha and 0.52% has tridoshaja presentation. There are over 100 treatment options available in Ayurveda to treat vitiligo. Each system of medicine recognizes the same disease albeit with minor difference in description. Skin care procedures like washing and emollients restore the barrier function and skin health. We have converged Ayurvedic skin care with that of dermatology with an aim of achieving patient management that is better than that achievable by a single system alone. Overload of the lymphatic system due to loss of epidermal barrier function and consequent inflammation from bacteria and soil irritants is responsive to selected Ayurvedic herbal preparations. It is evident that integration at the therapeutic level is possible, although the pathological basis is interpreted differently. Irrespective of background understanding of the given disease, a mutually oriented multisystem therapeutic team was able to effectively use medicines from more than one system of medicine and to develop guidelines for their prescription and a patient care algorithm.

Blockade of Transforming Growth Factor-β1 Accelerates Lymphatic Regeneration during Wound Repair

Lymphedema is a complication of cancer treatment occurring in approximately 50% of patients who undergo lymph node resection. Despite its prevalence, the etiology of this disorder remains unknown. In this study, we determined the effect of soft tissue fibrosis on lymphatic function and the role of transforming growth factor (TGF)-β1 in the regulation of this response. We determined TGF-β expression patterns in matched biopsy specimens collected from lymphedematous and normal limbs of patients with secondary lymphedema. To determine the role of TGF-β in regulating tissue fibrosis, we used a mouse model of lymphedema and inhibited TGF-β function either systemically with a monoclonal antibody or locally by using a soluble, defective TGF-β receptor. Lymphedematous tissue demonstrated a nearly threefold increase in the number of cells that stained for TGF-β1. TGF-β inhibition markedly decreased tissue fibrosis, increased lymphangiogenesis, and improved lymphatic function compared with controls. In addition, inhibition of TGF-β not only decreased TGF-β expression in lymphedematous tissues, but also diminished inflammation, migration of T-helper type 2 (Th2) cells, and expression of profibrotic Th2 cytokines. Similarly, systemic depletion of T-cells markedly decreased TGF-β expression in tail tissues. Inhibition of TGF-β function promoted lymphatic regeneration, decreased tissue fibrosis, decreased chronic inflammation and Th2 cell migration, and improved lymphatic function. The use of these strategies may represent a novel means of preventing lymphedema after lymph node resection.

Active exercises utilizing a facilitating device in the treatment of lymphedema resulting from breast cancer therapy.

The aim of this study was to evaluate the reduction in volume of arm lymphedema secondary to breast cancer therapy utilizing an exercise facilitating device. Twenty-one women with arm lymphedema resulting from the surgical and radiotherapeutic treatment of breast cancer were randomly selected. Evaluation was made by water-displacement volumetry before and after each session. The patients were submitted to a series of active exercises using a facilitating device for four 12-minute sessions with intervals of 3 minutes between sessions in the sitting position with alignment of the spinal column. The lymphedematous arm was maintained under compression using a cotton-polyester sleeve. The active exercising device used was a mobile flexion bar fixed on a metal base at a height of 30 cm from the tabletop and at a distance of 10 cm from the patient’s body. The paired t-test was utilized for statistical analysis with an alpha error of 5% (p-value ≤0.05) being considered significant. The initial mean volume of the arms was 2,089.9 and the final volume was 2,023.0 mL with a mean loss of 66.9 mL (p-value <0.001). In conclusion, active exercises utilizing facilitating devices can contribute to a reduction in size of lymphedematous limbs.

Lymphedematous Arm as Donor Site for Radial Forearm Free Flap in Thoracic Reconstruction

Sir: Recently, an article by Chang and Kim was published describing a large study of the incidence of lymphedema after mastectomy and radiotherapy, and after breast reconstruction with autologous flaps.1 This problem is a concern for every breast surgeon and remains controversial in the field of reconstructive surgery.2 Obviously, the real issue is for patients, who often avoid reconstruction to avoid risks related to surgery or further demolitions.3 In this way, we suggest an alternative free flap. We found that fasciocutaneous flaps could represent a valid alternative to muscular free flaps4—which represents one of the best alternatives—with an easy surgical technique and less morbidity, particularly when the patient refuses a contralateral latissimus dorsi free flap as in our case. We submitted four mastectomized patients suffering from radionecrosis and lymphedema to thoracic reconstruction with a radial forearm free flap taken from lymphedematous arm, to preserve the healthy arm (Fig. 1, above). We used the traditional procedure. Despite the lymphedematous tissues, dissection and harvesting of the flap was carried out with no difficulty (Fig. 1, below). The radial forearm free flap was successful in all cases. Flaps demonstrated long-term survival with easier surgical technique and less morbidity, particularly when harvested using a lymphedematous arm, and no worsening of the lymphedema was verified after surgery (Fig. 2, above). Despite initial scepticism, no disadvantages that we expected occurred, including an unsightly donor-site scar and skin graft breakdown with tendon exposure. The quality of our results seems to be stable, because actually no recidivism was verified and all the patients could return to their daily activities (Fig. 2, below).Fig. 1.: (Above) Preoperative view of radiodermitic wound in the thoracoaxillary region, with area of severe cutaneous distress and fistula in the right lateral district, associated with arm lymphedema. (Below) One year after surgery, improvement of surrounding tissues is observed because of trophism caused by the flap.Fig. 2.: (Above) Intraoperative view of flap sculpting from right lymphedematous limb, subsequently transferred and micro-anastomosed by means of two end-to-side anastomoses to the ipsilateral brachial vein and artery. (Below) Donor site 12 months after surgical treatment.We have proved that the radial forearm free flaps performed on lymphedematous upper limbs represented an adequate therapeutic choice, ascertaining the following: Upper limb lymphedema should not to be considered an absolute contraindication to perform microvascular radial forearm free flap surgery. The donor site shows normal healing without pathologic scars. Skin grafts taken at the donor site were successful, and no complications arose, despite the presence of lymphedema. In all patients, a great improvement was obtained, characterized by pain release and reduction of thoracic constriction. The lymphedematous swelling of the flap provided expanded and reliable tissue,5 which demonstrates that lymphedema does not represent a contraindication, making this the most conservative surgical procedure. In addition, lymphedema is not worsened after surgery and seems to be reduced in the long term. In our opinion, the radial forearm free flap offers several potential advantages over other fasciocutaneous flaps and muscle flaps for mastectomized patients and patients affected by radionecrosis undergoing thoracic reconstruction: it provides a large amount of well-vascularized, thin, pliable soft tissue; it is easy to harvest; and it has large consistent vessels and a long pedicle, particularly when, performing it, a lymphedematous donor site is used, which provides expanded tissue. Luca Vaienti, M.D. Laura Masetto, M.D. Giovanni Palitta, M.D. Plastic Surgery Department Università degli Studi di Milano Policlinico San Donato San Donato Milanese Milan, Italy Michel Merle, M.D. Institut Européen de la Main Hôpital Kirchberg Luxembourg

Diagnosis of peripheral lymph circulation disorders with contrast MR lymphangiography

To evaluate anatomical and functional images of contrast MR lymphangiography in the diagnosis of limb lymphatic circulation disorders. 30 patients with limb lymphedema were enrolled in the study. There were 27 patients of primary lymphedema and 3 of secondary lymphedema. Contrast enhanced lymphangiography was performed with 3.0 T MR Unit after intracutaneous injection of gadobenate dimeglumine into the interdigital webs of the dorsal foot and hand. The kinetics of enhanced lymph flow within the lymphatics were calculated using the formula: Speed (cm) = total length of visualized lymph vessel (cm)/ inspection time (minutes) and by comparing dynamic nodal enhancement and time-signal intensity curves between edematous and contralateral limbs. Morphological abnormalities of the lymphatic system were also evaluated. Following injection of the contrast agent enhanced lymphatic channels were consistently visualized in all clinical lymphedematous limbs and five contralateral limbs of unilateral lymphedema cases. The speed of enhanced flow within the lymphatics of lymphedematous limbs ranged from 0.30 to 1.48 cm/min. The contrast enhancement in inguinal nodes of edematous limbs was significantly lower than that of contralateral limbs (P < 0.01). Dynamic measurement of contrast enhancement showed a remarkable lowering of peak time (P < 0.01) and peak enhancement (P < 0.01) and a delay in outflow in inguinal nodes of affected limbs compared with that of control limbs. Post-contrast MR imaging also depicted varied distribution patterns of lymphatics and abnormal lymph flow pathways within lymph nodes in the limbs with lymphatic circulation disorders. Contrast MR lymphangiography with gadobenate dimeglumine was able to visualize the precise anatomy of lymphatic vessels and lymph nodes in lymphedematous limbs. It also provided comprehensive information about the functional status of lymph flow transportation in lymphatics and lymph nodes.