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Lymphedematous Arm as Donor Site for Radial Forearm Free Flap in Thoracic Reconstruction

Vaienti, Luca M.D.; Masetto, Laura M.D.; Palitta, Giovanni M.D.; Merle, Michel M.D.

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Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 1125-1127
doi: 10.1097/PRS.0b013e3181e3b819
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Sir:

Recently, an article by Chang and Kim was published describing a large study of the incidence of lymphedema after mastectomy and radiotherapy, and after breast reconstruction with autologous flaps.1 This problem is a concern for every breast surgeon and remains controversial in the field of reconstructive surgery.2 Obviously, the real issue is for patients, who often avoid reconstruction to avoid risks related to surgery or further demolitions.3 In this way, we suggest an alternative free flap. We found that fasciocutaneous flaps could represent a valid alternative to muscular free flaps4—which represents one of the best alternatives—with an easy surgical technique and less morbidity, particularly when the patient refuses a contralateral latissimus dorsi free flap as in our case. We submitted four mastectomized patients suffering from radionecrosis and lymphedema to thoracic reconstruction with a radial forearm free flap taken from lymphedematous arm, to preserve the healthy arm (Fig. 1, above). We used the traditional procedure. Despite the lymphedematous tissues, dissection and harvesting of the flap was carried out with no difficulty (Fig. 1, below). The radial forearm free flap was successful in all cases. Flaps demonstrated long-term survival with easier surgical technique and less morbidity, particularly when harvested using a lymphedematous arm, and no worsening of the lymphedema was verified after surgery (Fig. 2, above). Despite initial scepticism, no disadvantages that we expected occurred, including an unsightly donor-site scar and skin graft breakdown with tendon exposure. The quality of our results seems to be stable, because actually no recidivism was verified and all the patients could return to their daily activities (Fig. 2, below).

Fig. 1.
Fig. 1.:
(Above) Preoperative view of radiodermitic wound in the thoracoaxillary region, with area of severe cutaneous distress and fistula in the right lateral district, associated with arm lymphedema. (Below) One year after surgery, improvement of surrounding tissues is observed because of trophism caused by the flap.
Fig. 2.
Fig. 2.:
(Above) Intraoperative view of flap sculpting from right lymphedematous limb, subsequently transferred and micro-anastomosed by means of two end-to-side anastomoses to the ipsilateral brachial vein and artery. (Below) Donor site 12 months after surgical treatment.

We have proved that the radial forearm free flaps performed on lymphedematous upper limbs represented an adequate therapeutic choice, ascertaining the following:

  1. Upper limb lymphedema should not to be considered an absolute contraindication to perform microvascular radial forearm free flap surgery.
  2. The donor site shows normal healing without pathologic scars. Skin grafts taken at the donor site were successful, and no complications arose, despite the presence of lymphedema.
  3. In all patients, a great improvement was obtained, characterized by pain release and reduction of thoracic constriction. The lymphedematous swelling of the flap provided expanded and reliable tissue,5 which demonstrates that lymphedema does not represent a contraindication, making this the most conservative surgical procedure. In addition, lymphedema is not worsened after surgery and seems to be reduced in the long term.

In our opinion, the radial forearm free flap offers several potential advantages over other fasciocutaneous flaps and muscle flaps for mastectomized patients and patients affected by radionecrosis undergoing thoracic reconstruction: it provides a large amount of well-vascularized, thin, pliable soft tissue; it is easy to harvest; and it has large consistent vessels and a long pedicle, particularly when, performing it, a lymphedematous donor site is used, which provides expanded tissue.

Luca Vaienti, M.D.

Laura Masetto, M.D.

Giovanni Palitta, M.D.

Plastic Surgery Department

Università degli Studi di Milano

Policlinico San Donato

San Donato Milanese

Milan, Italy

Michel Merle, M.D.

Institut Européen de la Main

Hôpital Kirchberg

Luxembourg

REFERENCES

1.Chang DW, Kim S. Breast reconstruction and lymphedema. Plast Reconstr Surg. 2010;125:19–23.
2.Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps: Recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg. 2009;124:737–751.
3.Norman SA, Localio AR, Potashnik SL, et al. Lymphedema in breast cancer survivors: Incidence, degree, time course, treatment, and symptoms. J Clin Oncol. 2009;27:390–397.
4.Sandel HD IV, Davison SP. Microsurgical reconstruction for radiation necrosis: An evolving disease. J Reconstr Microsurg. 2007;23:225–230.
5.Zachary LS, Gottlieb LJ, Simon M, Ferguson MK, Calkins E Forequarter amputation wound coverage with an ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flap in patients undergoing palliative shoulder-girdle tumor resection. J Reconstr Microsurg. 1993;9:103–107.

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