Distally Based Lymphatic Microsurgical Preventive Healing Approach—A Modification of the Classic Approach

Abstract

The treatment of breast cancer has seen great success in the recent decade. With longer survivorship, more attention is paid to function and aesthetics as integral treatment components. However, breast cancer-related lymphedema (BCRL) remains a significant complication. Immediate lymphatic reconstruction is an emerging technique to reduce the risk of BCRL, the Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) being the most widely used approach. Despite promising results, it is often difficult to find suitably sized recipient venules and perform the microanastomoses between mismatched vessels deep in the axilla. Moreover, high axillary venous pressure gradients and potential damage from radiotherapy may affect the long-term patency of the anastomoses. From an ergonomic point of view, performing lymphaticovenular anastomosis in the deep axilla may be challenging for the microsurgeon. In response to these limitations, we modified the technique by moving the lymphatic reconstruction distally—terming it distally based LYMPHA (dLYMPHA). A total of 113 patients underwent mastectomy with axillary clearance in our institution from 2018 to 2021. Of these, 26 underwent subsequent dLYMPHA (Group 2), whereas 87 did not (Group 1). In total, 17.2% (15 patients) and 3.84% (1 patient) developed BCRL in Groups 1 and 2, respectively (p = 0.018). Lymphatics and recipient venules suitable for anastomoses can be reliably found in the distal upper limb with better size match. A distal modification achieves a more favorable lymphaticovenular pressure gradient, vessel match, and ergonomics while ensuring a comparably low BCRL rate.

Keywords

lymphedema - breast cancer - microsurgery - lymphovenous anastomosis

Authors' Contributions

Conceptualization: A.W-J.W., N.H.S.S., H.W.C., S.N., Y.O.K., J.J.F., T.W.W.P., B.K-T.T.

Formal analysis: A.W-J.W., N.H.S.S., W.X.

Methodology: A.W-J.W., N.H.S.S., H.W.C., S.N., C.B.T., S.L.

Project administration: A.W-J.W., N.H.S.S., C.B.T., S.L.

Visualization: H.W.C., S.N., Y.O.K., J.J.F., T.W.W.P., B.K.-T.T.

Writing—original draft: A.W-J.W., N.H.S.S., W.X.

Writing—reviewing and editing: A.W-J.W., N.H.S.S., W.X.

Ethical Approval

This study was approved by CIRB and conducted in accordance with the principles of the Declaration of Helsinki, under SingHealth Institutional Review Board Reference 2022/2619.

Patient Consent

Informed consent was obtained from patients prior to publication of their clinical photos.

Publikationsverlauf

Eingereicht: 05. Dezember 2023

Angenommen: 28. Mai 2024

Accepted Manuscript online:
30. Mai 2024

Artikel online veröffentlicht:
06. August 2024

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