Lymph Node Transfer for Lymphedema
The NOLA GABRs are pleased to announce that we will be the first ever in the United States to offer lymph node transfer surgery for patients with a history of upper and lower extremity lymphedema. Dr. Maria M. LoTempio trained under Corinne Becker, the doctor who pioneered the lymph node transfer, in Paris France.
Vascularized Lymph Node Transfer (VLNT) is a relatively new microsurgical procedure that involves transferring lymph nodes from the groin to the area under the arm. VLNT may be appropriate for women who have experienced complications during breast cancer surgery.
Although breast cancer surgery may be a life-saving procedure, complications sometimes make it necessary to remove lymph nodes under the arm. This can result in chronic swelling of the arm, known as lymphedema, which can cause pain and disfigurement of the arm and may also lead to infections. VLNT was developed to help reduce these undesirable side effects.
LYMPH NODE TRANSPLANTATION IN BREAST RECONSTRUCTION USING PERFORATOR FLAPS
Introduction: For many women undergoing breast reconstruction mastectomy, the negative impact of upper extremity lymphedema outweighs the benefits of breast reconstruction. Patients with lymphedema present a challenging problem, and typically it’s not addressed during the reconstruction process. Lymph node dissections have decreased secondary due to advent of the sentinel node biopsy. However, 7% of patients undergoing sentinel lymph node biopsy may develop lymphedema. Previous treatment options have not proved to be highly successful, and include lymphatic massage and lympaovenous anastomosis. We introduce a combined treatment for breast reconstruction using deep inferior epigastric perforator flap (DIEP) along with lymph node transplantation for lymphedema.
Methods: Beginning in 2007, 23 patients have undergone bilateral breast reconstruction using the DIEP along with simultaneous lymph node transplantation. Each patient had demonstrated upper extremity lymphedema by measurements and subjective findings. Of the 23 patients 18 had radiation therapy and five had sentinel node dissection. The lymph node flap was harvested surrounding the superficial circumflex vessels in conjunction with the DIEP. The combined DIEP and lymph nodes were anastomosed to the internal mammary artery. Preparation of the axilla included removal of scar tussue, and fixation of lymph nodes into the axilla.
Results: Each patient had an uncomplicated postoperative course. These patients started to experience resolutions of lymphedema as early as ten days after surgery and continue up to six months. Currently, 15 patients no longer need lymphatic massage nor wear an arm compression garment. One patient had a recurrence of breast cancer. Each patient reported their arm circumference had improved and decreased morbidity associated with lymphedema.
Conclusion: Lymph node transfer surgery is a relatively new and exciting option for the management of lymphedema. Women who undergo breast reconstruction using perforator flaps can have simultaneous lymph node transplantation with minimal morbidity. These patients experienced an overall 89% improvement of symptoms.
LYMPH NODE HARVEST
The patients are brought to the operating room. Once they undergo the deep inferior epigastric perforator flap harvest, an additional tissue comprising fat and lymph nodes is harvested as an attachment to the deep inferior epigastic perforator flap. The lymph nodes are indentified surrounding the circumflex iliac artery/vein. Visualization of one or two lymph nodes is seen and felt and then removed in conjunction with fat.
PREPARATION OF AXILLA
In order to receive the lymph node transfer flap, the preparation of the axilla needs to be performed. These are usually in women who have undergone a lymph node dissection with or without radiation treatment. An incision is made extending the mastectomy scar into the axilla. The fibrotic tissue (otherwise known as scar tissue) is removed in the axilla. Health tissue is visualized and ready for the recipient lymph node free flap.
PLACEMENT OF THE LYMPH NODES
The lymph node transfer flap is brought up to the chest wall. Once the microsurgical anastomoses are complete, the DIEP flap is placed into the breast pocket and the attached lymph node tranfer flap is then positioned into the axilla specifically covering the axillary vein. It is then sutured to the soft tissue in the area. The incisions are closed, and drains are placed into the axilla and surrounding new breast tissue.
AFTER THE PROCEDURE
Patients are admitted to the women’s unit, where they will have a four-day hospitalization stay. The morning of the first day, the patient’s Foley catheter, IV, and blood pressure oxygenation cables are discontinued. The patient is able to ambulate and tolerate a regular diet and void on her own. Over the next two to three postoperative days, flap observation and monitoring continues. The patient is ambulatory and tolerating postop antibiotics and a regular diet. On postop day three, providing that the drainage is minimal in the axilla and the breast, the drain is removed, and the patient undergoes lymphatic massage by a lymphatic therapist. In postop day four, the patient is discharged comfortably home.
Once home, the patient continues with the manual lymphatic drainage by herself or with her lymphatic therapist. A lymphatic therapist will be seen by the patient once a week, where measurements will be taken weekly and sent to the surgeon. Within seven days, the newly-placed lymph nodes should start taking effect.
IDENTIFYING CANDIDATES FOR VLNT
Candidates for VLNT are typically breast cancer patients treated with radiation and/or sentinel node and lymph node dissection.
Candidates can have VLNT as a stand-alone procedure or in conjunction with a Deep Inferior Epigastric Perforator (DIEP) flap, where skin and fatty tissue are similarly borrowed from the abdomen to replace tissue removed from the breast.
Candidates are usually in Stage 1 or Stage 2 and have undergone complete decongestive therapy. Patients must have a 200 cc volume change or 2cm measurement change to their contralateral arm. Patients must undergo lymphoscintigraphy to indentify lymph node activity in the axilla of the arm.
HOW WE WORK WITH YOU
At Omega Hospital we understand that many women view the breast as the embodiment of femininity. When patients come to us for help with complications stemming from previous treatment for breast cancer, we are sensitive to the emotional, psychological and physical aspects of the medical options they are exploring.
Compassion, empathy, and understanding are much more comforting words to us. They are the principles the distinguish Omega Hospital from other hospitals.
About Dr. LoTempio
Dr. Maria LoTempio is a New York-based plastic surgeon specializing in reconstructive and cosmetic surgery exclusively for women. In addition to technical skill and artistry, Dr. LoTempio also brings a distinctly female perspective to her work, with a deep understanding of the emotions a woman experiences when considering any kind of cosmetic or reconstructive surgery.
After graduating from the State University of New York at Buffalo School of Medicine, Maria LoTempio completed a six year residency program at UCLA working exclusively in head and neck surgery. In 2005, she began a second residency in plastic and reconstructive surgery at the Medical University of South Carolina. After completion of this program, she began a microsurgical breast reconstruction fellowship with Dr. Robert J. Allen, the pioneer of the perforator flaps in breast reconstruction. In early 2008, she was among the first US-based plastic surgeons to travel to France to train in the lymph node transfer surgery with Dr. Corrine Becker, and is one of only a few surgeons in the world today trained to treat lymphedema with Vascularized Lymph Node Transfer.