Multimodality Approach to Lymphedema Surgery Achieves and Maintains Normal Limb Volumes: A Treatment Algorithm to Optimize Outcomes

Abstract

Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridgeTM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridgeTM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (-4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to -1.0% (-3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.

Keywords: BioBridge; lymphangiogenesis; lymphaticovenous anastomosis; lymphedema; vascularized lymph node transfer.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1

Treatment algorithm for Stage II-III lymphedema.

Figure 2

All patients combined demonstrated a median relative volume excess of 29% (19.8, 43.3%). Following liposuction and physiologic procedures, volume excess was 0.5% (−4.3, 3.8%, p < 0.0001). After BB placement and completion of triple therapy surgery, median volume excess was −1 (−3.3, 1.3%, p < 0.0001). Data are presented as median values and IQR. Signficiant values (p < 0.05) are indicated by (***).

Figure 3

Upper extremity excess volume of 24% reduced to 3% at 9 months following combined VLNT and liposuction. BB was implanted at 12 months post-op resulting in the stabilized volume excess of 4% at 21 months following triple therapy surgical management.

Figure 4

Lower extremity with 27% excess volume reduced to 6% at 12 months following VLNT and liposuction. BB placement at 1 year post-op resulted in volume excess improvement to −3% at 24 months following triple therapy surgical management.

Figure 5

Lower extremity with 9% volume excess reduced to −1% at 11 months following VLNT/LVA and liposuction. BB placement at 12 months post-op resulted in −3% volume excess at 23 months following triple therapy surgical management.

Figure 6

Subgroup analysis of patient median volume excess ratio at baseline, after liposuction and physiologic surgery, and after BB placement. Data are presented as median values and IQR. Statistically significant values (p < 0.05) are indicated by an asterisk (*).