Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection—A Single Institution Experience and Feasibility of Technique

Abstract

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1–4 per axilla. The operating time ranged from 32–95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

Combined perforator flaps and lymphatic procedures in reconstructions after sarcoma resection

“…Many techniques have been developed to treat and reconstruct the damaged lymphatic network, but the real ongoing question is: should these become a standard preventative measure, to avoid any lymphatic complications at all? Up to this point, LVA has been the most broadly accepted technique in terms of prevention (Agarwal et al, 2020;Lipman et al, 2021;Wagner et al, 2022). This supermicrosurgical procedure consists in diverting the lymphatic flow into the systemic circulation by linking a lymphatic vessel to a nearby vein.…”

St. Gallen/Vienna 2023: Optimization of Treatment for Patients with Primary Breast Cancer – A Brief Summary of the Consensus Discussion

“…For situations of a negative posttreatment sentinel node, a relative majority of panelists (44%) voted for no further therapy, whereas 39% would still irradiate the axilla. The panel did not recommend LYMPHA [8, 9] surgery as routine but considered lymphatic surgery in general promising (64% yes) for the treatment of clinically relevant lymphedema.…”

Discussion: Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer–Related Lymphedema

“…9 Identifying the risk factors associated with BCRL is critical, given the increasing acceptance of prophylactic procedures (eg, lymphatic microsurgical prophylactic healing). 10,11 Therefore, in addition to risks posed by surgical and adjuvant therapies, risks posed by anatomical variants may enable risk stratification to identify the patients who are likely to benefit the most from preventative operations.…”