Share this article on:

Lymphedema of the Upper Extremity following Supraclavicular Lymph Node Harvest

Lee, Ming A.B.; McClure, Evan B.A.; Reinertsen, Erik B.S.; Granzow, Jay W. M.D., M.P.H.

Plastic and Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 1079e–1082e
doi: 10.1097/PRS.0000000000001253
Viewpoints

Emory University School of Medicine, Atlanta, Ga.

Emory University School of Medicine, and Goizueta Business School, Emory University, Atlanta, Ga.

Emory University School of Medicine, Wallace H. Coulter Department of Biomedical Engineering at Emory University, and Georgia Institute of Technology, Atlanta, Ga.

Division of Plastic Surgery, University of California, Los Angeles, Harbor–UCLA Medical Center and UCLA David Geffen School of Medicine, Los Angeles, Calif.

Correspondence to Dr. Granzow, Harbor-UCLA Medical Center, Department of Surgery, Box 25, 1000 West Carson Street, Torrance, Calif. 90509, drjay@plasticsurgery.la

Back to Top | Article Outline

Sir:

Vascularized lymph node transfer of lymph nodes from donor sites to affected sites can restore lymphatic flow and effectively treat lymphedema. A documented risk of vascularized lymph node transfer is the development of new lymphedema at or around the lymph node harvest donor site or limb. Studies have reported rare instances of donor-site lymphedema following lymph node flap harvest from axillary or groin donor sites.1–3

The supraclavicular area has been described previously as a donor site without risk of secondary lymphedema in the surrounding tissues, with some surgeons favoring this donor site because of the perceived lack of risk.4 We describe a patient who presented with lymphedema of the right arm following vascularized lymph node transfer from the right supraclavicular donor area to the left groin. The development of lymphedema in the right upper extremity following a supraclavicular node harvest challenges this previous notion that the supraclavicular area is without risk of donor-site lymphedema. Careful patient selection, surgical expertise, and methods such as reverse lymph node mapping may reduce this risk.5–8

A 55-year-old woman presented to our office after she developed lymphedema of the right arm approximately 2 years after she had vascularized lymph node transfer performed by another surgeon. She had initially developed left leg lymphedema after an epidural procedure. In the following year, the patient also developed lymphedema in the right leg (Fig. 1). The vascularized lymph node transfer procedure from the right supraclavicular fossa to the left groin was then performed by the other surgeon to treat the swelling (Fig. 2). The patient’s postoperative course was complicated by the accumulation of seroma containing milky fluid at the supraclavicular donor site, which resolved approximately 4 weeks after surgery with conservative treatment. Approximately 6 months after the vascularized lymph node transfer surgery, the patient developed lymphedema in her right arm. A volume excess of 1055 cc was present on follow-up examination (Fig. 3). Lymphoscintigraphic imaging before and after the vascularized lymph node transfer surgery revealed a significant decrease of tracer migration in the right arm and loss of visualization of tracer in the right axillary lymph nodes after the operation, consistent with lymphedema (Fig. 4).

Fig. 1

Fig. 1

Fig. 2

Fig. 2

Fig. 3

Fig. 3

Fig. 4

Fig. 4

Effective treatments for both congenital and secondary lymphedema have been documented extensively in the medical literature. Multiple studies have documented the effectiveness of conservative lymphedema therapy, vascularized lymph node transfer, lymphaticovenous anastomosis, and suction-assisted protein lipectomy for properly selected patients with lymphedema.5–14 Vascularized lymph node transfer involves transfer of lymph nodes and the surrounding soft tissue as a microsurgical free flap from a donor site to the affected area. This technique is most effective for the treatment of fluid-predominant lymphedema, and can reduce the need for compression garment use and lymphedema therapy. Furthermore, vascularized lymph node transfer can improve patient quality of life and dramatically reduce the risk of dangerous lymphedema cellulitis in affected individuals.5–14

This case challenges the previous notion that the supraclavicular donor site is free from postoperative lymphedema risk. Careful patient selection and anatomical dissection, surgeon experience with the vascularized lymph node transfer procedure, and the use of reverse lymphatic mapping may reduce such donor-site risk.

Back to Top | Article Outline

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

Ming Lee, A.B.

Emory University School of Medicine

Evan McClure, B.A.

Emory University School of Medicine, and

Goizueta Business School

Emory University

Erik Reinertsen, B.S.

Emory University School of Medicine

Wallace H. Coulter Department of Biomedical Engineering

at Emory University, and

Georgia Institute of Technology

Atlanta, Ga.

Jay W. Granzow, M.D., M.P.H.

Division of Plastic Surgery

University of California, Los Angeles

Harbor–UCLA Medical Center and

UCLA David Geffen School of Medicine

Los Angeles, Calif.

Back to Top | Article Outline

REFERENCES

1. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM.. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg. 2012;130:1246–1253
2. Vignes S, Blanchard M, Yannoutsos A, Arrault M.. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg. 2013;45:516–520
3. Pons G, Masia J, Loschi P, Nardulli ML, Duch J.. A case of donor-site lymphoedema after lymph node-superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg. 2014;67:119–123
4. Althubaiti GA, Crosby MA, Chang DW.. Vascularized supraclavicular lymph node transfer for lower extremity lymphedema treatment. Plast Reconstr Surg. 2013;131:133e–135e
5. Granzow JW, Soderberg JM, Kaji AH, Dauphine C.. An effective system of surgical treatment of lymphedema. Ann Surg Oncol. 2014;21:1189–1194
6. Granzow JW, Soderberg JM, Kaji AH, Dauphine C.. Review of current surgical treatments for lymphedema. Ann Surg Oncol. 2014;21:1195–1201
7. Granzow JW, Soderberg JM, Dauphine C.. A novel two-stage surgical approach to treat chronic lymphedema. Breast J. 2014;20:420–422
8. Dayan JH, Dayan E, Smith ML.. Reverse lymphatic mapping: A new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135:277–285
9. Cheng MH, Huang JJ, Huang JJ, et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol. 2012;126:93–98
10. Basta MN, Gao LL, Wu LC.. Operative treatment of peripheral lymphedema: A systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg. 2014;133:905–913
11. Patel KM, Lin CY, Cheng MH.. From theory to evidence: Long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers. J Reconstr Microsurg. 2015;31:26–30
12. Becker C, Assouad J, Riquet M, Hidden G.. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315
13. Lin CH, Ali R, Chen SC, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123:1265–1275
14. Patel KM, Cheng MH.. A prospective evaluation of lymphedema-specific quality of life outcomes following vascularized lymph node transfer. Plast Reconstr Surg. 2014;133:1008
Back to Top | Article Outline

GUIDELINES

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

  • Text—maximum of 500 words (not including references)
  • References—maximum of five
  • Authors—no more than five
  • Figures/Tables—no more than two figures and/or one table

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2015American Society of Plastic Surgeons