The “String of Pearls” technique for increased surface area and lymphedematous fluid drainage in right gastroepiploic‐vascularized lymph node transfer: A report of two cases

Fan, Kenneth L.; Black, Cara K.; Song, David H.; Corral, Gabriel A. Del

doi:10.1002/micr.30484

Cited by 4 publications

(4 citation statements)

References 24 publications

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“…79 A VLNT can be combined with free tissue transfer and LVB for individuals pursuing simultaneous breast reconstruction. 79,80 NIRF-L, when combined with staging scales (e.g., the Koshima ICG Classification System, MD Anderson Cancer Center (MDACC) scale, and the Dermal Backflow Scale (DBS)), is considered the "gold standard" imaging modality for the diagnosis, severity staging, and surgical planning of LVB (Figure 2). 31,46,[81][82][83][84][85][86] The perioperative use of NIRF-L permits precise lymphatic mapping and is more predictive of outcomes than ISL.…”

Section: Surgical Planningmentioning

confidence: 99%

Surgical Techniques for Lymphovenous Bypass: A Review

K. Tom

2024

IJCCR

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Background: Lymphedema is a progressive, debilitating disease that may affect up to 250 million individuals worldwide. Complex decongestive therapy (CDT) remains the first line of treatment for lymphedema, and surgical treatment currently has no formally established role. In recent years, lymphovenous bypass (LVB) has emerged as a potentially efficacious intervention to improve patients' objective and subjective measures of lymphedema. Despite this promise, there are few evidence-based recommendations to inform the adoption of the practice. Methods: A narrative review of the present literature on LVB was performed through a query of records using various combinations of Medical Subject Heading (MeSH) terms and keywords such as “lymphatic vessels,” “lymphedema,” “breast cancer lymphedema,” “surgical anastomosis,” “lymphovenous bypass,” “lymphovenous anastomosis.” The articles were assessed for 1) bibliometric characteristics, 2) preoperative evaluation, 2) operative techniques, 3) postoperative regimens, and 4) outcome measures. Results: The sixty-year evolution of LVB has transformed rapidly in response to technological advances in the last two decades. The geographically distributed investigation of these surgical innovations has prompted a fragmentation of LVB practice. As original research outpaces literature review, there needs to be more consistency in terminology, perioperative practices, and evaluation of outcomes of LVB, which challenge systematic analysis. The systematic reviews to date emphasize the ability of LVB to improve objective measures such as limb circumference. Still, the inconsistent use of subjective measures limits our appreciation of the collective improvement in patient-reported outcomes. Moreover, there are a limited number of accepted methods for patient selection, preoperative evaluation, and surgical planning, with many surgical techniques employed. Conclusion: The unifying principles and scientific evidence must be clarified to guide an overarching consensus before the widespread adoption of LVB. This article aims to synthesize recommendations and current institutional preferences concerning the research and clinical applications of LVB. The collaboration and continued refining of these practices will be necessary to establish the role of LVB in the treatment and prevention of lymphedema.

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Section: Surgical Planningmentioning

confidence: 99%

Surgical Techniques for Lymphovenous Bypass: A Review

K. Tom

2024

IJCCR

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“…1,2 Several studies have proposed methods to reduce venous congestion in VLNT, which include intraflap arteriovenous fistulas, venous supercharging, and a flow-through omental VLNT flap with two arterial end-to-end anastomoses. 1–6…”

Section: Operative Technique and Outcomesmentioning

confidence: 99%

“…1,2 Several studies have proposed methods to reduce venous congestion in VLNT, which include intraflap arteriovenous fistulas, venous supercharging, and a flowthrough omental VLNT flap with two arterial end-to-end anastomoses. [1][2][3][4][5][6] We present a novel operative approach to VLNT that combines the advantages of a functional flow-through flap with the addition of two arterial end-to-side anastomoses to treat patients with chronic upper and lower extremity lymphedema. The following will detail the course of six consecutive female patients with chronic lymphedema who underwent a supraclavicular or submental flowthrough VLNT using this technique between June 2021 and September 2022 (Table 1).…”

Section: Operative Technique and Outcomesmentioning

confidence: 99%

Functional Flow-through Vascularized Lymph Node Flap with Two End-to-Side Arterial Anastomoses: A Technical Report

Mella-Catinchi

Finkelstein

2023

Plastic and Reconstructive Surgery - Global Open

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Summary: Vascularized lymph node transfer (VLNT) is a reliable treatment for patients with chronic lymphedema. Capillary networks in VLNT are less robust than those in traditional free tissue transfers, possibly contributing to venous congestion when a single arterial and venous anastomosis is performed. This technical report describes a novel operative technique and associated advantages to a functional flow-through VLNT with two end-to-side arterial anastomoses. Six consecutive patients with upper or lower extremity lymphedema received buried supraclavicular or submental VLNT with two end-to-side arterial anastomoses and at least one venous anastomosis. Recipient arteries in the anastomoses were the brachial artery for patients with upper extremity lymphedema (n = 4), and the posterior tibial vasculature in patients with lower extremity lymphedema (n = 2). Five patients simultaneously underwent lymphovenous bypass. Mean patient follow-up was 14 months. Average preoperative Lymphedema Life Impact Score and L-DEX (bioimpedance spectroscopy measurement) were 25 points and 31.4 units, with a mean greatest decrease of 20 points and 9.4 units postoperatively (n = 5). The loop configuration created by flow-through VLNT with two end-to-side arterial anastomoses may reduce pressure gradients within the flap by limiting arterial inflow and thus, mitigate the risk of venous hypertension. Additional benefits of this approach include elimination of mismatch caliber discrepancies often appreciated in end-to-end arterial anastomosis between the lymph node flap and the recipient artery, and preservation of the recipient artery anatomy.

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“…To minimize venous hypertension in the omental vascularized lymph node transplant, the addition of a secondary venous outflow has been proposed. 8 In the upper extremity, we proposed a novel inset with a second arterial and venous anastomosis, thereby recreating the omentum's natural flowthrough physiology. 5 In this case series, we describe our lower extremity approach to omental vascularized lymph node transplantation with a middle leg recipient site and flowthrough configuration.…”

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confidence: 99%

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity

Lee

Granoff

Pardo

et al. 2022

Plastic &Amp; Reconstructive Surgery

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Summary: Vascularized lymph node transplantation is a surgical approach for the treatment of chronic lymphedema. However, there is no clinical standard for flap placement nor vascular anastomoses. The authors propose a novel flowthrough configuration for an omental vascularized lymph node transplant in the popliteal space. To prepare the popliteal space for an omental free flap, the medial popliteal fat pad and medial head of the gastrocnemius muscle were debulked. Venous anastomoses were completed with vein couplers, joining the right gastroepiploic vein to the medial sural venae comitantes and the left gastroepiploic vein to the lesser saphenous vein. Arterial anastomoses were hand sewn, joining the right gastroepiploic artery to the proximal medial sural artery and the left gastroepiploic artery to the distal medial sural artery, to create the flowthrough configuration. A retrospective review of patients who underwent this procedure at a single institution was performed. Six patients with chronic lymphedema of the lower extremity underwent vascularized lymph node transplantation from June of 2019 to November of 2020. Five patients underwent at least 3 months of postoperative surveillance, with no postoperative complications reported. In this technique contribution, the authors describe a novel flowthrough configuration for an omental free flap to the popliteal space. The popliteal space offers an aesthetically favorable recipient location when appropriately prepared. The medial sural vessels are ideal recipient vessels for the flowthrough omental flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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The “String of Pearls” technique for increased surface area and lymphedematous fluid drainage in right gastroepiploic‐vascularized lymph node transfer: A report of two cases

Cited by 4 publications

References 24 publications

Surgical Techniques for Lymphovenous Bypass: A Review

Surgical Techniques for Lymphovenous Bypass: A Review

Functional Flow-through Vascularized Lymph Node Flap with Two End-to-Side Arterial Anastomoses: A Technical Report

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity

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