V. Surgical Treatment in Lymphology

Abstract

Chieh-Han John Tzou^{1, 2, 3}, Joon Pio Hong⁴, Jung-Ju Huang⁵, Ines Tinhofer^{1, 6}, Viktoria A. Kampfer¹, Nina Huettinger^{1, 7}, Julia Roka-Palkovits^{1, 8}, Johannes Steinbacher^{1, 9}, David Habin Song¹⁰, Christoph Wallner^{11, 12}, Felix Reinkemeier^{11, 12}, Alexander Wolff^{11, 12}, Marcus Lehnhardt^{11, 12}, Ahmed M. Gad¹³, Jasmin Rast¹, Ielyzaveta Omelchenko¹, Naim Abuzarifa¹, Manuel Cornely¹⁴

¹Department of Plastic and Reconstructive Surgery, Department of Surgery, Hospital of the Divine Savior, Vienna, Austria

²Faculty of Medicine, Sigmund Freud University Vienna, Austria

³TZOU MEDICAL., Lymphology Center, Vienna, Austria

⁴Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea

⁵Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipeh, Taiwan

⁶Medicine in Neuwaldegg, Vienna, Austria

⁷Ordination Hüttinger, Vienna, Austria

⁸Med Vienna Center, Joint Practice, Vienna, Austria

⁹Ordination Steinbacher, Purkersdorf, Austria

¹⁰MedStar Georgetown University Hospital, Washington, D.C., USA

¹¹University Clinic for Plastic Surgery and Hand Surgery, Centre for Severe Burn Injuries, Sarcoma Centre Bergmannsheil Bochum

¹²University Hospital Bergmannsheil, Bochum, Germany

¹³Ain Shams University, Cairo, Egypt

¹⁴LY.SEARCH gGmbH, Düsseldorf, Deutschland

For years, lymphedema has been a global health issue with millions of sufferers worldwide. Plastic Surgeons are faced with new innovations in lymphedema diagnostics and surgery. Joon Pio Hong reports combined use of ICG, MR lymphangiograms and high-definition ultrasound to specifically select lymphatics as efficient surgical therapies. Various anastomoses between lymphatic vessels/veins and lymph nodes/veins show promising outcomes. New evidence confirms the effectiveness of preventive lymphatic surgery, which provides hope to treat conditions once more difficult.

Breast reconstruction restores the breast shape, maintains quality of life and minimizes the psychological impact of losing a breast after mastectomy. Jung-Ju Huang addresses successful, standardized, innovative breast reconstruction surgery with robot-assisted mastectomy, robot-assisted DIEP flap harvest, and superficial breast neurotization.

Restoration of breast sensitivity is an integral part of breast reconstruction. Ines Tinhofer, Viktoria Kampfer, Nina Huettinger, Julia Roka-Palkovits, and Johannes Steinbacher report objectively- measurable restoration of breast sensation and increased quality of life for post-mastectomy patients with sensitively reinnervated, autologous breast reconstructions.

Vascularized omentum lymph node transplant (VOLT) is a promising microsurgical option for treating lymphedema and restoring lymphatic drainage. David Habin Song reports on a significant volume reduction in the lymphedematous arm and the elimination of recurrent cellulitis with the VOLT technique. VOLT offers notable advantages, such as simultaneous two-team surgery, minimal donor site morbidity, and improved postoperative recovery.

Surgical treatment of extremity sarcomas requires extensive tissue removal, leading to significant postoperative issues such as lymphedema and seroma formation. Christoph Wallner, Felix Reinkemeier, Alexander Wolff, and Marcus Lehnhardt show the oncological safety and therapeutic benefits of lymphaticovenous anastomosis (LVA) as a preventive and curative method in post-traumatic lymphedema and extremity sarcoma patients.

Complex trauma, venous insufficiency and lymphatic dysfunction lead to chronic leg ulcers, which negatively affect patients’ quality of life. Ahmed M. Gad reports on patients with multiple failed skin grafting and recurrent cellulitis, in whom reduction of lymphedema and healing of chronic leg ulcers are observed after lymphaticovenous anastomosis (LVA) operation.

Supermicrosurgical lymphaticovenous anastomosis (LVA) represents a promising therapeutic approach for patients with lymphedema and requires high-level supermicrosurgical skills as well as precise preoperative planning and execution. Jasmin Rast, Aaron Metz, Ielyzaveta Omelchenko, Naim Abuzarifa, Nina Huettinger, Julia Roka-Palkovits, Ines Tinhofer and Johannes Steinbacher introduce three innovative intraoperative techniques to simplify the LVA procedure and optimize outcomes: a spray film system for securing preoperative markings, a plug-in cannulation method for LVA with sclerotic lymphatic vessels and a fat pad to protect LVA operation sites before wound closure.

Number: 28

Keynote

Recent innovations in lymphedema surgery. Further evidence

Joon Pio Hong

Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea

For years, lymphedema has been a global health issue with millions of people worldwide bearing the devastating sequelae of filariasis. Recently, with the advent of oncological treatments and increased survival of cancer patients, the profound burden of lymphedema both on the individual and society has been increasingly recognized in developed countries, too. This has not only prompted heightened interest in the health care community but has also generated increased awareness among the patients themselves. To this end, surgeons and other specialist convene to discuss treatment options and multidisciplinary approaches. As plastic surgeons, we are faced with new innovations in lymphedema surgery, especially microsurgical intervention. How we find evidence and incorporate it in our daily practice will make a pivotal difference in outcome for this very difficult-to-treat condition.

Most critical innovations in lymphedema surgery are in the field of diagnostics. The use of ICG and MR lymphangiograms allows us to visualize lymphatics and now with high definition ultrasound, we are able to find functioning lymphatics and make the surgery efficient. Intraoperative approaches and results on various anastomoses between lymphatic vessels and veins are also showing different outcomes. Furthermore, lymph node-to-vein anastomosis is showing some promise of better outcome in selected patients. More understanding of postoperative compression care helps with better outcome as well.

Lymphedema surgery is now providing hope to once thought difficult to treat condition. Furthermore, there is new evidence showing that preventive lymphatic surgery may be effective. Staying up to date on the innovations will allow the surgeon to select the correct indications and adequate treatment options.

Number: 29

A sense of wholeness: current stage of breast reconstruction

Jung-Ju Huang

Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan

Introduction/Background: Breast reconstruction is now becoming a part of breast cancer surgery to restore the breast shape, maintain quality of life and minimize the psychological impact of losing a breast after mastectomy. With the gradual development, breast cancer survival has been largely enhanced, and early diagnosis also makes cancer control much better. Over the past 15 years, the breast reconstruction team has dedicatedly worked with breast surgeons to minimize breast cancer surgery and deliver reconstruction, including robot-assisted mastectomy, robot-assisted DIEP flap harvest, and breast neurotization to bring the reconstruction to the most flaw-free outcome. The team has performed about 250 cases of robot-assisted mastectomy with different reconstruction methods. The innovative superficial breast neurotization makes the procedure applicable in different reconstruction scenarios. Robotics also can be applied in DIEP flap harvest to further minimize donor site morbidities. In this talk, the current status of mastectomy trends and reconstruction results will be fully covered.

Number: 30

Clinical data of sensate breast reconstructions in the Hospital of the Divine Savior

Ines E.Tinhofer^{1, 2}, Viktoria A. Kampfer¹, Nina V. Huettinger^{1, 3}, Julia Roka-Palkovits^{1, 4}, Johannes Steinbacher^{1, 5}, Chieh-Han John Tzou^{1, 6, 7}

¹Department of Plastic and Reconstructive Surgery, Hospital of the Divine Savior, Vienna, Austria

²Medicine in Neuwaldegg, Vienna, Austria

³Ordination Huettinger, Vienna, Austria

⁴Med Vienna Center, Joint Practice, Vienna, Austria

⁵Ordination Steinbacher, Purkersdorf, Austria

⁶Faculty of Medicine, Sigmund Freud University, Vienna, Austria

⁷TZOU MEDICAL., Lymphology Center, Vienna, Austria

Introduction: This study examines the breast sensitivity of the sensitively-reinnervated, autologous breast reconstructions performed between June 2020 and August 2023 at the Divine Savior Hospital, Vienna.

Methodology: The postoperative sensitivity tests were carried out as part of the follow-up checks with the help of Semmes-Weinstein monofilaments (baseline® fold-up™ monofilaments). For this purpose, each breast was divided into nine quadrants and the minimum perceptible measured value was noted in each case. Eleven breast reconstructions were performed on nine patients, two bilateral and seven unilateral. Eight reconstructions were secondary and one primary. The following flapplasties were used: one TMG, two msTRAM, two SIEA and six DIEP flapplasties. The sensitive coaptation was performed in a total of ten flapplasties, seven in the third ICR and three in the fourth ICR. At least two postoperative measurements per patient were carried out and included in the evaluation.

Results: The median of each quadrant was 5.43 (15-26g) monofilament index at primary measurement at 21.9 months, and 4.81 (6-8g) monofilament index at maximum follow-up, at 31.2 months. In the first measurement, only the first quadrant was in the range of “diminished protective sensation” (0.6g – 2g). At max. follow-up, quadrants one to four were in the range of diminished protective sensation. The first and fourth quadrants had the lowest monofilament index at 3.84, corresponding to 0.6g of pressure sensitivity. The largest difference between first and maximum follow-up was documented in the third quadrant. This monofilament index decreased from 5.99 (60-100g) to 4.53 (2-4g), which corresponds to a deviation of 1.47 of the index.

Inference: Although our results could not reach significance due to the small number of cases, they clearly indicate that autologous, sensitively-revitalized breast reconstruction can achieve a restoration of breast sensitivity.

Number: 31

Lymphedema and omentum

David Habin Song

MedStar Georgetown University Hospital, Washington, D.C., USA

Background: Lymphedema, a chronic condition characterized by the accumulation of lymphatic fluid, leads to limb swelling, recurrent infections, and decreased quality of life. Vascularized omentum lymph node transplant (VOLT) is a promising microsurgical option for the treatment of lymphedema, offering the potential to restore lymphatic drainage. This study reports on the outcomes of five patients who underwent VOLT for upper extremity lymphedema, utilizing different recipient vessels and vein flow-through techniques.

Materials and Methods: Five patients with upper extremity lymphedema underwent VOLT. In two patients, the internal mammary artery and vein were used as recipient vessels, with a branch of the cephalic vein utilized as a flow-through. In the other three patients, the thoracodorsal artery and vein served as recipient vessels, and the basilic vein was used as a flow-through. Patient follow-up ranged from 6 months to 3 years, with a mean follow-up of 13 months. Lymphedema volume reduction was measured postoperatively, and the incidence of recurrent cellulitis was documented.

Results: All five patients demonstrated a significant reduction in lymphedematous arm volume, with a decrease ranging from 20% to 40%. Notably, no episodes of recurrent upper arm cellulitis were observed in any patient following VOLT. Patients experienced improved limb functionality and reduced discomfort. The vascularized omentum grafts showed effective integration with minimal complications, and donor site morbidity was negligible, promoting early postoperative mobility and reduced pain.

Conclusion: VOLT presents a promising treatment option for lymphedema, offering notable advantages such as a simultaneous two-team surgery, minimal donor site morbidity, and improved postoperative recovery. The procedure resulted in substantial volume reduction and eliminated recurrent cellulitis in the follow-up period. Further studies are needed to confirm these findings and assess long-term outcomes.

Number: 32

Surgical methods for treating extremity lymphedema after injuries and tumors

Christoph Wallner^{1, 2, 3}, Felix Reinkemeier^{1, 2, 3}, Alexander Wolff^{1, 2, 3, 4}, Marcus Lehnhardt^{1, 2, 3, 4}

¹University Clinic for Plastic Surgery and Hand Surgery

²Centre for Severe Burn Injuries

³Sarcoma Centre Bergmannsheil Bochum, Germany

⁴University Hospital Bergmannsheil, Bochum, Germany

Introduction/Background: Surgical treatment of extremity sarcomas often requires extensive tissue removal, leading to significant postoperative issues such as lymphedema and seroma formation. Lymphaticovenous Anastomosis (LVA) is gaining attention as a technique that could address these complications by enhancing lymphatic drainage. This study investigates the oncological safety and therapeutic benefits of using LVA both as a preventive and curative approach in patients with extremity sarcomas, including patients experiencing post-traumatic lymphedema.

Material and Methods: In this prospective study, 45 patients who underwent LVA were followed for an average of 14 months post-surgery. Key outcomes measured included the occurrence of metastasis, local tumor recurrence, seroma formation, and the development of lymphedema, with a particular focus on post-traumatic cases. A control group without LVA treatment was also analyzed for comparison.

Results: The LVA group showed no cases of metastasis or local recurrence during the follow-up period, while the control group experienced higher rates of these oncological events. Moreover, the LVA group had significantly lower instances of seroma formation and lymphedema, including post-traumatic lymphedema, compared to those who did not receive LVA.

Conclusion: LVA appears to be a safe and effective method for reducing postoperative complications such as seroma formation and lymphedema, including cases related to trauma, in patients undergoing surgery for extremity sarcomas. These promising results support the integration of LVA into standard surgical protocols for extremity sarcomas. Further research with extended follow-up is necessary to confirm the long-term benefits and safety of this approach.

Number: 33

Role of LVA in chronic leg ulcers

Ahmed M. Gad

Ain Shams University Cairo, Egypt

ORCID Number: 0000-0002-6563-5678

Introduction/Background: Chronic leg ulcers, which negatively affect patients’ quality of life, have a diverse etiology. Venous insufficiency and lymphatic dysfunction lead to leg edema and delay wound healing. Also, trauma accompanied mainly by multiple orthopedic interventions in addition to complications precipitate leg ulcers.

Material and Methods: Four patients with chronic leg ulcers with different underlying etiologies were included in this case report. These cases do not respond to regular management including wound care, compression, and vascular surgery procedures. Also, they suffered from multiple failed attempts at skin grafting. They reported recurrent attacks of cellulites and wound infection. Two to three level Lymphatico- venous Anastomosis (LVA) were done in the four patients.

Results: All of the patients reported improvement of healing a few weeks following the surgery. One had complete healing after 3 years of ulceration. The other records show progressive wound shrinkage.

Conclusion: LVA and proper control of edema have a promising role in the healing of chronic leg ulcers

Number: 34

Technical ideas and innovation in LVA surgery

Jasmin Rast¹, Aaron Metz¹, Ielyzaveta Omelchenko¹, Naim Abuzarifa¹, Nina Huettinger¹, Julia Roka-Palkovits¹, Ines Tinhofer¹, Johannes Steinbacher¹, Chieh-Han John Tzou^{1, 2, 3}

¹Department of Plastic and Reconstructive Surgery, Hospital of the Divine Savior, Vienna, Austria

²Faculty of Medicine, Sigmund Freud University, Vienna, Austria

³TZOU MEDICAL., Lymphology Center, Vienna, Austria

Introduction: Supermicrosurgical Lymphaticovenous Anastomosis (LVA) represents a promising therapeutic approach for patients with lymphedema, yet it requires high-level supermicrosurgical skills as well as precise preoperative planning and execution. This paper introduces three innovative pre- and intraoperative techniques, developed and scientifically evaluated at our center to simplify the LVA procedure and optimize outcomes.

1. Spray Film System for Securing Preoperative Markings

Lymphatic vessels and suitable veins are identified and marked on skin 1–2 days prior to surgery using high-resolution ultrasound.¹ Currently, Tegaderm™ film (3M Company, St. Paul, MN, USA) is used to protect these markings. Instead, we propose the use of a spray film system (OPSITE® Spray, Smith & Nephew GmbH, Watford, UK), which forms a thin, transparent layer within 3 minutes post-application.² This method represents a time- and cost-effective alternative to the traditional film dressing.

2. Plug-in Cannulation Method for LVA

Our plug-in method employs a blunt, bent cannula (4 mm bend from the tip, angled at 30°, 27G, Ø 0.5 mm, Eagle Labs, Rancho Cucamonga, CA, USA) to stabilize the venous lumen. The cannula is inserted into the collapsed vein, enabling a technically precise transluminal suture. This practical technique is especially useful in cases where standard LVA is not feasible due to lymphatic vessel fibrosis or extreme size mismatch.

3. Anastomosis Protection Pad

By inserting a small amount of surrounding adipose tissue, a protective sliding layer is created between the LVA and the skin closure. This fat pad reduces mechanical stresses, such as pressure or gravitational forces, and may improve LVA outcomes.

Conclusion: The presented techniques optimize the LVA procedure by enhancing preoperative preparation and intraoperative precision, with the potential to improve postoperative outcomes.

REFERENCES

Mohos B, Czedik-Eysenberg M, Steinbacher J, Tinhofer I, Meng S, Tzou CJ. Long-term Use of Ultrasound for Locating Optimal LVA Sites: A Descriptive Data Analysi. J Reconstr Microsurg. 2022 Mar;38(3):238-244 https://doi.org/10.1055/s-0041-1740124. Epub 2021 Nov 24. PMID: 34820800.

Ghosh SJ, Kumar K, Gilbert PM. Opsite spray: its use for fixation of meshed skin grafts. Simple and low tech. Burns. 1997 Nov-Dec;23(7-8):601-3. https://doi.org/10.1016/s0305-4179(97)00066-PMID: 9568332.

Yamamoto T, Fisher M, Liao J, Carr J, Chen W. The “Octopus” Lymphaticovenular Anastomosis: Evolving Beyond the Standard Supermicrosurgical Technique. Journal of Reconstructive Microsurgery. 2015;31(06):450-457. https://doi.org/10.1055/s-0035-1548746