Dorsal Wrist Placement for Vascularized Submental Lymph Node Transfer Significantly Improves Breast Cancer–Related Lymphedema

Abstract

Background:Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer–related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patients. This study compared the treatment response of breast cancer–related lymphedema with the placement of vascularized submental lymph node flaps at the wrist, between dorsal and volar recipient sites.Methods:A retrospective longitudinal study examined 15 patients receiving vascularized submental lymph node flaps at the wrist performed by a single surgeon with a mean follow-up of 17 months. Clinical and biometric analyses, including quality of life questionnaires, circumference measurements, and number of infections were conducted.Results:All patients showed improvements in quality of life, reduced episodes of cellulitis, and reduced limb circumference measurements compared with preoperative data. Dorsal placement (n = 7) delivered significant reductions in limb circumference at all levels after 1 year (P = 0.04) and in overall function domains in the Lymphedema Specific Quality of Life Questionnaires (P = 0.04) compared with volar placement (n = 8). Venous outflow was greater in the dorsal recipient veins (P < 0.0001).Conclusions:Patients electing to undergo vascularized lymph node transfer to the wrist should be aware that when both options are effective, dorsal placement offers improvement in outcomes despite reduced cosmesis. These results have been incorporated into an evidence-based treatment algorithm that can inform the patient and physician on the decision-making in the breast and plastic surgical spheres.

Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema

“…Where heterotopic transfer was indicated, the preferred lymph node flaps were the submental, lateral thoracic, jejunal mesenteric, or right gastroepiploic, using either the radial or ulnar recipient vessels, depending on the distribution of the dermal backflow; dorsal transfer was performed when indicated using the dorsal radial vessels. 38 Localized direct excision of fibroadipose soft tissues, including the typically thickened deep fascia, was performed to provide a pocket for the lymph node flap and to allow tension-free primary skin closure; occasionally, a small temporary skin graft was used to relieve tension that was excised later in the clinic. Where residual obstructed lymphatic channels were identified on indocyanine green lymphography, lymphovenous bypass (LVB) was also performed.…”

Evaluation of Free vascularized groin lymph nodes transfer for treatment of secondary upper limb lymphedema

“…For the VGLNT group, there are three recipient sites available for lymph tissue transfer with a lot of controversy in the literature. 29 Despite the axillary area is typically operated previously and irradiated, which makes the dissection of recipient's vessels harder, the release of the scary fibrotic tissue and decompression of the axillary veins could improve the lymphatic obstruction so, we used usually when lymphedema treatment was combined with breast reconstruction using DIEP flap. Distal lymph node flap placement has the benefits of intact healthy recipient vessels and improving distal limb lymph drainage against gravity.…”

A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema

“…In 2018, Aljaaly et al also reported on the QoL after VLNT. (30) They found that the general QoL increased significantly with 5.5 points and that all the subdomains scored decreased significantly. Upon subgroup analysis they found that, after 12 months, patients who received a VLNT to the volar side of the wrist instead of the dorsal side had a better score regarding the general QoL and the appearance subdomains (p<0.05).…”

“…However, only eight studies reported outcomes of both the healthy and affected extremity, or the decrease in extremity differences compared to the difference prior to surgery. (15,(24)(25)(26)(27)(28)(29)(30) These eight studies were analysed and the results are demonstrated in a forest plot (Figure 2). The mean reduction of the volume difference between the healthy and affected extremities was 40.31% (CI 31.44-49.17).…”

“…Of all included studies, five evaluated patients QoL after VLNT. (28,30,32,35,36) Four studies used the LYMQOL questionnaire. This validated questionnaire rates four specific domains (function, appearance, symptoms and mood) with a score from one to four in addition to a general QoL rating from one to ten.…”