The Scientific Committee invites to submission of abstracts to the Barcelona Breast Meeting to be held in Barcelona on 14-17 March 2017.

Submissions are invites for presentations of interest in Lymphedema surgery, Revisional surgery, Breast complex surgery or Problem cases.

Key dates:
  • Abstract submission: 21st February 2017
  • Notification of acceptance: 28th February 2017

6th WSLS Free paper sessions

Wednesday, 15th March 2017. From 07:00h to 08:00h.

07:00 – 07:07h:

Name: M. Garcés
Organization: Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau. Anatomy and Embriology Department, Universitat Autonoma de Barcelona. Clinica Planas, Barcelona.
Paper title: Intra-flap lymphovenous Communications and their role in the mechanism of action of vascularized lymph node transfer and lymphedema surgery

Intra-flap lymphovenous communications and their role in the mechanism of action of vascularized lymph node transfer and lymphedema surgery

MIRANDA GARCÉS MD [2][3]; Gemma PONS MD, PhD[1]; Rosa MIRAPEIX MD, PhD[3]; Jaume MASIÀ MD, PhD [1][2].
1. Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau/Universitat Autonoma de Barcelona, Sant Antoni Maria Claret 167, 08025 Barcelona, Spain.
2. Clinica Planas, Barcelona, Spain
3. Anatomy and Embriology Department, Universitat Autonoma de Barcelona, Building M, Avinguda de Can Domenech, 08193, Bellaterra, Barcelona, Spain.

Abstract: Vascularized lymph node transfer has shown beneficial effects as a surgical treatment for cancer-related lymphedema although its mechanism of action is not fully understood. After an exhaustive bibliographic review, we studied the presence of natural intratissue lymphovenous communications (LVC) in flaps used for breast reconstruction. We propose LVC as a fundamental element to consider in the mechanism of action of vascularized lymph node transfer as they would allow the drainage of lymph to blood through the venous system [1,2].

Methods: This prospective study determined the passage of lymph to the venous system via intratissue LVC in 26 free flaps used for breast reconstruction. To determine the passage of lymph to the venous system via peripheral LVC, we used indocyanine green (ICG) fluorescence lymphography. After injecting intradermal ICG in the free flaps, we studied the presence of ICG in the pedicle vein after increasing time intervals.

Results: We studied 26 free flaps, including deep inferior epigastric perforator (DIEP) flaps (84.6%) and superior gluteal artery perforator (SGAP) flaps (15.4%). Fluorescence in the pedicle vein was positive in 22 of the 26 flaps (p=0.000).

Conclusions: Fluorescence in the pedicle vein after ICG intradermal injection indicates functional intratissue LVC in free flaps because their lymphatic system is disrupted.

1. Miranda Garces, M., et al., A comprehensive review of the natural lymphaticovenous communications and their role in lymphedema surgery. J Surg Oncol, 2016 Jan; 113 (4):374-380
2. Miranda Garcés M, et al., Intratissue lymphovenous communications in the mechanism of action of vascularized lymph node transfer, J Surg Oncol. 2017 Jan;115(1):27-31

07:08 – 07:15h:

Name:  S. Akita
Organization: Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
Paper title: Prefabricated Lympho-Venous Shunt Increases the Efficacy of Lymph Node Transfer for Lower Extremity Lymphedema

Prefabricated Lympho-Venous Shunt Increases the Efficacy of Lymph Node Transfer for Lower Extremity Lymphedema

Shinsuke Akita, M. D., Ph. D.
Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan

Background: We developed two new tactics to increase the efficacy of vascularized lymph node transfer (LNT) for lower extremity lymphedema (LEL): the multiple lymph node flaps (LNFs) and the prefabricated lympho-venous shunt. In this study, the efficacy of each method was compared with that of conventional single LNT.

Methods: The results of LNT for LEL were compared between the conventional single LNT group (control group; n = 21 limbs), the multiple LNFs group (n = 13), and the prefabricated lympho-venous shunt group (n = 13) in terms of volume improvement (the LEL index), lymphoscintigraphy findings, and the rate of functional survival and lymph node sizes (evaluated using ultrasonography) at 6 months after surgery.

Results: LEL index was significantly improved in the prefabricated lympho-venous shunt group compared with the control group (P = 0.02). In the prefabricated lympho-venous shunt group, functional survival of transferred lymph nodes was confirmed in all cases and the average size of transferred lymph nodes at 6 months after transfer was significantly larger than in the control group. Although multiple LNFs did not increase morbidity at the donor site, it had no efficacy advantage over the control group.

Conclusions: Although further investigation is necessary, prefabricated lympho-venous shunt may increase the efficacy of LNT and prevent sclerosis of transferred lymph nodes in the long term. Ultrasonographic monitoring for sclerosis and change in the size of transferred lymph nodes may be useful in evaluating long-term results following LNT.

07:16 – 07:23h:

Name:  Y. Seki
Organization: St. Marianna University School of Medicine Department of Plastic and Reconstructive Surgery. Shonan Atsugi Hospital
Paper title: Early Result of Three Lymphaticovenular Anastomoses for Upper Extremity Lymphedema: Limitation and Future Strategy

Early Result of Three Lymphaticovenular Anastomoses for Upper Extremity Lymphedema: Limitation and Future Strategy

Yukio Seki, MD[1],[2]; Akiyoshi Kajikawa, MD[1] ;Takayuki Takeuchi, MD[1],[2]; Takahiro Terashima, MD[2]; Norimitsu Kurogi, MD[2]
1. St. Marianna University School of Medicine Department of Plastic and Reconstructive Surgery
2. Shonan Atsugi Hospital

Background: Lymphaticovenular anastomosis (LVA) is an effective, minimally invasive surgical treatment for upper extremity lymphedema (UEL). Multiple LVAs are recommended in treating lymphedema, because the efficacy of LVA has been reported to correlate with the number of LVAs. However, multiple LVAs have difficulty to keep several microsurgeons and operation microscopes simultaneously. We try to clarify the efficacy of fixed number of three LVAs which can be performed by one microsurgeon as first line surgical treatment for UEL.

Methods: The study involved ten patients with ISL stage 2 UEL characterized by stage 3-4 arm dermal backflow in indocyanine green lymphography [1]. All patients were treated by three LVAs at the upper extremity in local anesthesia. The lymphatic vessel diameter and direction of flow were assessed intraoperatively, and reduction in lymphedema volume was assessed postoperatively.

Results: Mean diameter of the lymphatic vessel was 0.375 ± 0.114 mm. In 16 of 30 anastomoses showed lymph-to-venous flow without venous reflux intraoperatively. Mean follow up was 13.6 ± 5.8 months. The circumference of the affected limb was reduced in eight patients. Mean volume reduction in the upper extremity lymphedema index was 8.038 ± 9.218 [2].

Discussion: Surgical treatment using fixed number of three LVAs is effective for majority of UEL patients with reduction in the stiffness and size of the affected limb. Although two patients in this study didn’t reveal enough improvement, LVA is useful as minimally invasive surgical treatment with early and continuous effect without donor site morbidity. Further investigation to develop breakthrough in LVA for UEL is expected.

1. Yamamoto T, et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011; 128(4):941-947.
2. Yamamoto T, et al. Upper extremity lymphedema index: a simple method for severity evaluation of upper extremity lymphedema. Ann Plast Surg. 2013 Jan;70(1):47-49.

07:24 – 07:31h:

Name:  T. Yamamoto
Organization: Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital
Paper title: Navigation Lymphatic Supermicrosurgery for Lymph Node Transfer

Navigation Lymphatic Supermicrosurgery for Lymph Node Transfer

Takumi Yamamoto, Nana Yamamoto, Hidehiko Yoshimatsu, Mitsunaga Narushima, Isao Koshima
Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital

Background: Supermicrosurgical lymphaticovenular anastomosis (LVA) has become a useful option for treatment of lymphedema refractory to conservative treatments [1,2]. However, LVA is not effective for severe lymphedema with severe lymphosclerosis. Lymph node transfer (LNT) is considered effective even for cases with severe lymphosclerosis, but has a possible risk of donor site lymphedema. We have introduced indocyanine green (ICG) lymphography navigation and supermicrosurgical technique in LNT [3-5].

Methods: ICG lymphography-navigated supermicrosurgical LNT was performed on severe lower extremity lymphedema (LEL) patients. Vascularized lymph node true perforator flaps were selectively harvested based on a true perforator branched from the lateral thoracic, the intercostal, or the thoracodorsal vessels under ICG lymphography at the lateral thoracic region. Flaps were supermicrosurgically transferred to lymphedematous lesions in a perforator-to-perforator anastomosis fashion. Perioperative morbidity and postoperative results were evaluated

Results: LNT operations were performed on 102 severe lymphedema patients, which resulted in 218 LNTs. 88% limbs were refractory to prior LVA. After LNT, 82% of the limbs showed volume reduction, and 94% showed reduction in cellulitis frequency. No perioperative complications were detected. There was no donor site lymphedema (0%; 0/102); no subjective symptom regarding lymphedema nor abnormal finding on postoperative arm ICG lymphography.

Conclusions: Supermicrosurgical LNT allows clinical improvements of lymphedema even refractory to LVA, and is recommended for patients with severe lymphedema refractory to LVA. Supermicrosurgical technique and ICG lymphography navigation are essential to maximize efficacy and to minimize morbidity in LNT surgery.

1. Yamamoto T, Narushima M, Yoshimatsu H, et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014;72(1):67-70.
2. Yamamoto T, Narushima M, Kikuchi K, et al. Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg 2011;127(5):1987-92.
3. Yamamoto T, Narushima M, Doi K, et al. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg 2011;127(5):1979-86.
4. Yamamoto T, Yoshimatsu H, Koshima I. Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea: supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg 2014;67(11):1573-9.
5. Yamamoto T, Yoshimatsu H, Yamamoto N. Complete lymph flow reconstruction: a free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis. J Plast Reconstr Aesthet Surg 2016 Jul 2 [epub ahead of print]

07:32 – 07:39h:

Name:  E. Siim
Organization: Department of Plastic Surgery. Department of Clinical Physiology and Nuclear Medicine. Department of Hematology, Herlev Gentofte University Hospital, Denmark
Paper title: Lymphatico-venular microsurgery for limb lymphedema – the Danish LVA approach

Lymphatico-venular microsurgery for limb lymphedema – the Danish LVA approach

Elsebeth Siim[1], Caroline Asirvatham Gjørup[1], Bo Zerahn[2], Lars Thorbjørn Jensen[2], Tobias W. Klausen[3], Tina Tos[1]
1. Department of Plastic Surgery
2. Department of Clinical Physiology and Nuclear Medicine
3. Department of Hematology, Herlev Gentofte University Hospital, Denmark

Introduction: Since 2013 our unit has performed lymphovenous anastomoses (LVA) as the only unit performing this type of surgery in Denmark. Patients are referred to us on a nationwide basis. Our presentation will cover the results of the first 35 consecutive patients operated on from 2013-2016 with a minimum of six month follow-up.

Materials and Methods: All patients underwent preoperative indocyanin green (ICG) lymphography (PDE scans), circumference measurements, conventional lymphoscintigraphy and volume and tissue composition assessment with dual energy X-ray absorptiometry (DXA).

The LVA surgery was performed following PDE scan and with perioperative use of patent blue to visualize the lymphatics.

The procedures were performed by two (super)-microsurgeons with the patients under regional anesthesia or general anesthesia.

Results: Results will be presented on the first 35 patients having undergone LVA surgery with a minimum of six months follow-up, clinical assessments, pre- and postoperative patients-reported outcomes, DXA measurements of the limbs and lymphoscintigraphy.

Conclusion: LVA surgery is a safe procedure with minor postoperative complications. Improvement was seen in the majority of cases (approx. 70% of the arms and 50% of the legs) associated with lower stages of LE and shorter duration of LE. Also an increased number of LVA’s seemed to improve the outcome.

07:40 – 07:47h:

Name:  J. C.-S. Yang
Organization: Division of Plastic and Reconstructive Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital, Taiwan
Paper title: Intraoperative Identification of “Functional” Lymphatic Ducts for Supermicrosurgical Lymphatico-Venous Anastomosis

Intraoperative Identification of “Functional” Lymphatic Ducts For Supermicrosurgical Lymphatico-Venous Anastomosis

Johnson Chia-Shen Yang MD, FACS
Division of Plastic and Reconstructive Surgery, Department of Surgery Kaohsiung Chang Gung Memorial Hospital, Taiwan

Introduction: Supermicrosurgical lymphatico-venous anastomosis (LVA) has played a major role in reducing lymphedema via venous drainage system. Identifying “functional” lymphatic ducts (LDs) is critical for LVA. Indocyanine green (ICG) lymphography has gained popularity in identifying functional LDs preoperatively. We purposed that other than ICG-enhanced LDs, LDs with gross lymphatic flow should also be regarded as functional too.

Patients and Methods: From March 2016~January 2017, 56 consecutive lymphedema patients (8 male/48 female; Average age 61.2 (36-81yrs), stage II~III) received supermicrosurgical LVA at our hospital. The LDs were observed directly under microscope (Pantero 900, Carl Zeiss AG, Oberkochen, Germany) after ICG injection, before LVAs were performed. LDs with/without gross lymphatic flow, and with/without ICG enhancement were recorded.

Results: A total of 239 incisions, 457 LVAs from 366 LDs, 262 veins, were performed in 56 patients (8 upper limbs/48 lower limbs), averaging 4.3 incisions, 8.2 LVAs, 6.5 LDs, and 4.7 veins per patient. Gross antegrade lymphatic flow was found under microscope in 258 LDs (258/366=70.5%); 198 LDs with antegrade flow are also ICG(+) (198/258=76.7%; 198/366=54.1%); but 60 LDs with antegrade flow are ICG(-) (60/258=23.3%; 60/366=16.4%). No gross lymphatic flow was found in 108 LDs (108/366=29.5%), however, 36 LDs without flow are ICG(+) (36/108=33.3%; 36/366=9.8%). A total of 234 ICG-enhanced LDs (with/without lymphatic flow) ((198+36=234)/366=63.9%) were identified with MINIRL before LVA. Total functions LDs=(LDs with gross flow + LDs without flow but ICG-enhanced)= (258+36)/366=80.3%.

Discussion and Conclusions: Up to 16.4% of functional LDs can be neglected if one depends solely on ICG enhancement because they are ICG(-) but with lymphatic flow. However, without ICG enhancment, 9.8% of functional LDs without gross lymphatic flow but are ICG(+) can be missed. A microscope equipped with MINIRL can be a valuable tool for maximizing the number of functional LDs when performing LVA.

1. Yamamoto T, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, Hara H, Koshima I. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014 Jan;72(1):67-70. doi: 10.1097/SAP.0b013e3182605580.
2. Yamamoto T1, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, Hara H, Koshima I. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014 Jan;72(1):67-70. doi: 10.1097/SAP.0b013e3182605580.
3. Yamamoto T1, Yamamoto N, Azuma S, Yoshimatsu H, Seki Y, Narushima M, Koshima I. Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery. 2014 Jan;34(1):23-7. doi: 10.1002/micr.22115. Epub 2013 Jul 9.
4. Chang DW1, Suami H, Skoracki R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013 Nov;132(5):1305-14. doi: 10.1097/PRS.0b013e3182a4d626.
5. Yamamoto T1, Yamamoto N, Numahata T, Yokoyama A, Tashiro K, Yoshimatsu H, Narushima M, Koshima I. Navigation lymphatic supermicrosurgery for the treatment of cancer-related peripheral lymphedema. Vasc Endovascular Surg. 2014 Feb;48(2):139-43. doi: 10.1177/1538574413510979. Epub 2013 Nov 13.

07:48 – 07:55h:

Name:  H. Hara
Organization: Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital. Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital
Paper title: Pathology of primary lymphedema and the indication of lymphatico-venous anastomosis (LVA)

Title: Pathology, imaging findings, and surgical treatment for genital lymphedema and acquired lymphangiectasia – Genital Pathway Stage (GPS)

Hisako Hara, Makoto Mihara, Isao Koshima
Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital
Department of Plastic and Reconstructive Surgery, The University of Tokyo Hospital

Background: Genital lymphedema and acquired lymphangiectasia are challenging conditions which is sometimes difficult to treat [1]. The purpose of this study was to better understand the pathology of genital lymphedema and acquired lymphangiectasia.

Methods: We performed lymphoscintigraphy and ICG lymphography for the 40 lower limb lymphedema patients, and established Genital Pathway Stage (GPS). We also examined the pathological characteristics of acquired lymphangiectasia in 16 biopsies from 10 patients [2]. Surgical specimens were fixed in formalin, and tissue sections were stained with hematoxylin–eosin. Additional immunostaining (podoplanin, lymphatic vessel endothelial hyaluronan receptor [LYVE] -1, CD4, CD8, CD20, and CD31) was performed in some cases.

Results: In some patients, lymphatic pathway from the lower limb to the genital region was observed in ICG lymphography and lymphoscintigraphy. Dilation of lymphatic vessels in the papillary dermis was present in all 10 cases of acquired lymphangiectasia. Infiltration of inflammatory cells, most of which were lymphocytes, was also observed in the dermis and the epidermis in all cases, even though there were no clinical signs of inflammation [2]. The infiltrating lymphocytes were mainly CD4+ T cells, and less commonly, CD8+ T cells and CD20+ B cells. The number of three types of lymphocytes was significantly larger in the superficial layer of the dermis than in the deep layer, which may indicate that they oozed out from the dilated lymphatic vessels located in the superficial dermis. CD8+ T cells infiltrated the epidermis in seven of eight specimens.

Conclusions: Lymphatic dilation and proliferation of collagenous fiber in the dermis were seen in cases of acquired lymphangiectasia, which indicated increased lymphatic inner pressure [3-5]. Constant infiltration of lymphocytes in the dermis and the epidermis may have a relation to frequent cellulitis, which is frequently seen in patients with acquired lymphangiectasia.

[1] Chang MB, Newman CC, Davis MD, Lehman JS. Acquired lymphangiectasia (lymphangioma circumscriptum) of the vulva: Clinicopathologic study of 11 patients from a single institution and 67 from the literature. Int J Dermatol. 2016 Sep;55(9):e482-7.
[2] Hara H, Mihara M, Anan T, Fukumoto T, Narushima M, Iida T, Koshima I. Pathological Investigation of Acquired Lymphangiectasia Accompanied by Lower Limb Lymphedema: Lymphocyte Infiltration in the Dermis and Epidermis. Lymphat Res Biol. 2016 Sep;14(3):172-80.
[3] Hara H, Mihara M, Ohtsu H, Narushima M, Iida T, Koshima I. Indication of Lymphaticovenous Anastomosis for Lower Limb Primary Lymphedema. Plast Reconstr Surg. 2015 Oct;136(4):883-93.
[4] Hara H, Mihara M, Seki Y, Todokoro T, Iida T, Koshima I. Comparison of indocyanine green lymphographic findings with the conditions of collecting lymphatic vessels of limbs in patients with lymphedema. Plast Reconstr Surg. 2013 Dec;132(6):1612-8.
[5] Hara H, Mihara M, Hayashi A, et al. Therapeutic strategy for lower limb lymphedema and lymphatic fistula after resection of a malignant tumor in the hip joint region: A case report. Microsurgery 2014; 34:224–228.

07:56 – 08:03h:

Name:  C. Hadamitzky
Organization: Plastic Surgery Helios Clinic Hildesheim
Paper title: Guided Lymphangiogenesis for the Treatment of Lymphedema: Preliminary Clinical Results

Guided Lymphangiogenesis for the Treatment of Lymphedema: Preliminary Clinical Results

Caterina Hadamitzky
Plastic Surgery Helios Clinic Hildesheim

Abstract: To address the limitations of current treatments for secondary lymphedema, our study group developed an experimental surgical procedure based on Autologous Lymph Node Fragment (ALNF) transfer supplemented by nanofibrillar collagen scaffold with and without autologous Adipose Derived Stromal Cells out from the stromal vascular fraction (ADSCs). The efficacy of this scaffold was demonstrated before in a porcine model of secondary lymphedema. To address the challenges of poor survival and low migration from the injection site described in clinical studies of ADSCs, we used ADSC-seeded scaffolds to deliver the cells. These scaffolds seem to support cell survival, maintenance and function at the targeted site. The ongoing pilot study has 12 patients currently enrolled. We used non-vascularized autologous lymph node fragment transfer (LNFT) as a basic treatment for all patients. It was supplemented by implantation of: BioBridge scaffolds (n=5); BioBridge scaffolds with ADSCs (n=2); BioBridge scaffolds with injected ADSCs (n=1); and injected ADSCs only (n=4; control group still ongoing). In the therapy groups no complications have been reported after almost one year. 6 of 8 patients using BioBridge responded to the treatment after 6 months with an average volume reduction of about 20%. Two of these patients have attained a normal limb volume ratio (≤1.1) at 3 months after surgery. The average edema reduction in the control group (n=4) was only 1.1% at 4 months after surgery. More data will be presented at the time of the conference. While vascularized lymph node transfer is considered to be a more advanced technique than ALNF transfer, there is a great interest in developing countries to have a simpler surgery to manage lymphedema without the need of a microscope. On the other hand, the concept of guiding lymphangiogenesis with collagen scaffolds could also potentially improve the efficiency of well-established vascularized lymph node procedures.

Apendix: This technology represents the first attempt to reverse secondary lymphedema through the use of aligned nanofibrillar collagen scaffold combined with Mesenchymal Stromal Cell (MSC) therapy as a means to promote and direct lymphangiogenesis to reconnect the disrupted lymphatics.

The BioBridge scaffold has been designed to provide an open 3D structure composed of aligned collagen fibrils, which allows the cells to attach throughout the scaffold and guides their migration along the fibrils. This nanofibrous collagen scaffold mimics the nanotopography of the native extracellular matrix and determines the organization of the cells and their phenotype, promoting new vessel formation. It is designed to safely dissolve within 6 – 9 months after implantation. BioBridge is approved as 510(k) device by FDA and approved by IRB of Stanford University for lymphedema treatment, the related IDE is pending.

In addition to comprehensive safety testing in support of the 510(k), several in vitro and in vivo studies performed in collaboration with Stanford University have shown that cells seeded on Biobridge scaffolds demonstrate significantly higher production of growth factors compare to the cells in culture plates; they also show high viability and retention1; BioBridge scaffolds enhance cell survival in ischemic conditions2; BioBridge with plated endothelial cells significantly increases vascular density2; BioBridge scaffold along induces directional angiogenesis and lymphangiogenesis3. The thread-like form factor of the scaffold is ideal for minimally invasive percutaneous implantation to bridge the area damaged by cancer surgery (cadaver study has been conducted by Dr. Dung Nguyen in Stanford University).

The choice of autologous MSCs from stromal vascular fraction (SVF) for enhancement of BioBridge-induced lymphangiogenesis is based on the safety and potential efficacy of this cell population. The autologous fat grafting with SVF enrichment for post-surgical breast reconstruction is a widely used procedure accepted by oncologists and plastic surgeons4. Implantation of the cells attached to the BioBridge scaffold further localizes their therapeutic effect. SVF isolation was based on the Stanford University IRB protocol5 and the abdominal adipose-derived stem cells. They were be tested using the single-cell technology and adipogenic, vasculogenic, and osteogenic differentiation assays according to established methods5.

MSCs are capable of expressing a lymphatic phenotype when exposed to lymph-inductive media6. The migratory activity toward VEGF-C in vitro suggests homing capability in vivo. Restoration of lymphatic drainage after injection of MSCs in a lymphedema model indicates that MSCs play an important role in lymphatic regeneration6. This effect was further investigated in-vitro7. It was found that stimulation of MSCs with VEGF-C significantly increased expression of VEGF-A, VEGF-C and Prox-1. MSCs stimulated with VEGF-C prior to implantation induced a significant (threefold increase) lymphangiogenic response as compared with control groups. Stimulation of the cells with VEGF-C resulted in a marked increase in the number of donor MSCs (twofold; p < 0.01) and increased the number of proliferating cells (sevenfold; p < 0.01). We hypothesize that by bridging the affected area with BioBridge scaffold in lymphedema patients, we enabled a VEGF-C gradient along the scaffolds from the proximal healthy lymph nodes due to the high capillarity and multi-luminal nature of the BioBridge. Thus, the exposition of MSCs plated on the scaffold to this gradient may be the reason for the enhancement of lymphangiogenesis.

Recent clinical study in Europe8 using freshly isolated SVF for lymphedema treatment and our pilot clinical study in the Dominican Republic9 demonstrated safety of both SVF injection and of their implantation within BioBridge plated with cells. In our European study8 about 4×107 cells were injected with 10 ml of lipoaspirate in the axillary region of one patient. Four months after treatment, the patient reported an improvement in daily symptoms, reduction in need for compression therapy, and volume reduction of the affected arm. There were no adverse effects. The preliminary results of our pilot study in the Dominicna Republic9 are mentioned above.

1. Huang NF, Okogbaa JN, Lee JC, Paukshto M, Zaitseva T, Cooke JP. The modulation of endothelial cell morphology, function, and survival using anisotropic nanofibrillar collagen scaffolds. Biomaterials. 2013 34:4038-4047.
2. Nakayama KH, Hong G, Lee JC, Patel J, Edwards B, Zaitseva TS, Paukshto MV, Dai H, Cooke JP, Woo YJ, Huang NF. Aligned-Braided Nanofibrillar Scaffold with Endothelial Cells Enhances Arteriogenesis. ACS Nano. 2015. 9(7):6900-8.
3. Hadamitzky C, Zaitseva TS, Bazalova-Carter M, Paukshto MV, Hou L, Strassberg Z, Ferguson J, Matsuura Y, Dash R, Yang PC, Kretchetov S, Vogt PM, Rockson SG, Cooke JP, Huang NF. Aligned nanofibrillar collagen scaffolds – Guiding lymphangiogenesis for treatment of acquired lymphedema. Biomaterials. 2016 Sep;102:259-67.
4. Bielli A., Scioli AM, Gentile DP, Cervelli DV, Orlandi A., Adipose Tissue-Derived Stem Cell Therapy for Post-Surgical Breast Reconstruction – More Light than Shadows. Adv Clin Exp Med 2015, 24, 3, 545–548.
5. Benjamin Levi, M.D., Jason P. Glotzbach, M.D., Michael Sorkin, M.D., Jeong Hyun, M.D., Michael Januszyk, M.D., Derrick C. Wan, M.D., Shuli Li, Ph.D., Emily R. Nelson, M.D. Michael T. Longaker, M.D., M.B.A., and Geoffrey C. Gurtner, M.D. Molecular Analysis and Differentiation Capacity of Adipose-Derived Stem Cells from Lymphedema Tissue. Plast Reconstr Surg. 2013 September ; 132(3): 580–589.
6. Conrad C1, Niess H, Huss R, Huber S, von Luettichau I, Nelson PJ, Ott HC, Jauch KW, Bruns CJ. Multipotent mesenchymal stem cells acquire a lymphendothelial phenotype and enhance lymphatic regeneration in vivo. Circulation. 2009 Jan 20;119(2):281-9.
7. Yan A, Avraham T, Zampell JC, Haviv YS, Weitman E, Mehrara BJ. Adipose-derived stem cells promote lymphangiogenesis in response to VEGF-C stimulation or TGF-β1 inhibition. Future Oncol. 2011 Dec;7(12):1457-73.
8. Toyserkani NM, Jensen CH, Sheikh SP, Sørensen JA. Cell-Assisted Lipotransfer Using Autologous Adipose-Derived Stromal Cells for Alleviation of Breast Cancer-Related Lymphedema. Stem Cells Transl Med. 2016 Jul;5(7):857-9.
9. Hadamitzky C, Zaitseva TS, Katz N., Escarraman MT., Nguyen D., Paukshto MV. Pilot Clinical Study of Guided Lymphangiogenesis. 2016 National Lymphedema Network Conference, September 1, 2016.

Wednesday, 15th March 2017. From 15:30h to 16:30h.

15:30 – 15:37h:

Name: Z. Jandali
Organization: Department of Plastic, Aesthetic, Reconstructive and Hand Surgery Evangelisches Krankenhaus, Medical Campus University of Oldenburg Germany
Paper title: Microsurgical Lymphaticovenous Anastomosis for Treatment of Recalcitrant Lymphatic Fistulas of the Lower Extremity

Microsurgical Lymphaticovenous Anastomosis for Treatment of Recalcitrant Lymphatic Fistulas of the Lower Extremity

Z. Jandali, B. Merwart, S. Zachariah, M. C. Lam , W. Steege, M. Koujan, L.P. Jiga.
Department of Plastic, Aesthetic, Reconstructive and Hand Surgery Evangelisches Krankenhaus, Medical Campus University of Oldenburg, Germany

Objective: Lymphatic fistulas represent a rare but severe complication following surgery in the lower extremity. Spontaneous regression can occur, nevertheless persistent Fistulas lead to lymphoceles, recurrent infections and sever soft tissue compression, resulting in significant disability of the patients. The treatment of lymphatic fistulas is being controversially discussed, the actual scientifical data lacking evidence on when conservative measures have failed, when surgery becomes mandatory, or which is the most optimal surgical approach. Here, we present our experience with treatment of recalcitrant lymphatic fistulas in the lower extremity using lymphaticovenous anastomosis (LVA).

Methods: Between 2011 and 2016, nineteen patients (mean age 52,5 years old) with persisting lymphatic fistulas were referred to our department, after undergoing either vascular surgery in the groin region (n=3), thigh lifting (n=6) or pelvic lymphadenectomy (n=2). All patients received between 1 and 5 LVAs, while in two patients pedicled gracilis flaps were additionaly employed to cover existing soft tissue defects. The mean operative time was 135,5 minutes. The mean follow up time was 24 months.

Results: All fistulas have been successfully treated using lymphaticovenous anastomosis. The mean hospital stay was 5,5 days. The lymphatic leakage ceased completely within 24 hours after surgery in all patients. None of the patients experienced neither a recurrence of the lymphatic fistulas nor other surgery-related complications within the mean follow-up time.

Discussion: Microsurgical lymphaticovenous anastomosis is a viable tool for effective treatment of recalcitrant lymphtatic fistulas in the lower extremity. Thus, further studies for development of microsurgical approach standards for treatment of this severe condition are certainly warranted.

15:38 – 15:45h:

Name: T. Aung
Organization: Center of Plastic, Hand and Reconstructive Surgery, University Medical Center
Paper title: Restoration of lymphatic function: free vascularized lymph node transfer with afferent lymphaticolymphatic and afferent lymphatico-nodular anastomosis

Restoration of lymphatic function: free vascularized lymph node transfer with afferent lymphaticolymphatic and afferent lymphatico-nodular anastomosis

T. Aung1, M. Ranieri[1], R. Müller-Wille[2], W.A. Wohlgemuth2, Katja Evert[3], L. Prantl[1], J. Dolderer[1]
1. Center of Plastic, Hand and Reconstructive Surgery, University Medical Center Regensburg, Germany
2. Department of Radiology, University Hospital Regensburg, 93042, Regensburg, Germany.
3. Department of Pathology, University Regensburg, Regensburg, Germany

Abstract: Abstract: Lymphatic malformations (LMF) are characterized by abnormal formation of lymphatic vessels and tissue overgrowth. The lymphatic vessels present in LMF lesions may become blocked and enlarged as lymphatic fluid collects, forming a mass or multicyst. Lesions are typically diagnosed during childhood, and are often disfiguring and life threatening. Available treatments consist of sclerotherapy, surgical removal and therapies to diminish complications.

Lymphatic malformations in inguinal region and inguinal lymphnode dissection is a challenging operation to occur without lower extremity lymphedema (LEL). Here, we report the first case of the resection of a lymphatic malformation and Dissection of the inguinal Lymph node and simultaneously we complete the reconstruction with mini6th WORLD SYMPOSIUM ON LYMPHEDEMA SURGERY abdominal plastic with vascularized lymph node transfer (VLNT) from ipsilateral and free VLNT from contralateral suprainguinal lymphnode with afferent lymphaticolymphatic anastomosis(ALLA) and Afferent lymphatico nodular anastomosis (ALNA).

The VLN was harvested from the ipsilateral and contralateral suprainguinal region under Indocyanine green (ICG) lymphography and patent blau navigation and transferred to the right goin region. The efferent lymph vessel of the VLN was supermicrosurgically anastomosted to the contralateral medial thigh lymphatic vessel.

Postoperative, there were no subjective or objective lymphedema on the right side and further on the left side. The patient needed nomore compression garment and manual lymph drainage. Further postoperative ICG lymphography showed the restoration of the lymphatic function.

15:46 – 15:53h:

Name: V. Ivashkov
Organization: Russian Cancer Recearch Center
Paper title: Transferred lymphatic nodes mapping after simultaneous breast reconstruction and lymphnodes autotransplantation.

Transferred lymphatic nodes mapping after simultaneous breast reconstruction and lymphnodes autotransplantation.

MD. Vladimir Ivashkov, PhD. Vladimir Sobolevsky.
Russian Cancer Research Center, Moscow, Russia.

Abstract: ICG technology is routinely used method for the most of specialists who interested in lymhedema treatment [1]. In Russian Federation this scientific area still undeveloped. We try to summarize our own experience and show one more elegant point of application the ICG technology. We used fluorescence lymphography technology to control the functional activity of the transplanted lymph nodes as a alternative method to radiotracer uptake[2]. For all patients who undergone lymphatic node transplantation we used ultrasound examination of transferred lymhonodes, but the anatomical visualization not showing functional activity. Despite the accurate visualization of the transplanted lymph nodes by ultrasonography in 100% of patients we set the goal to assess the functional activity of the lymph nodes and neolimphangiogenesis. Since the physical capacity of photodynamic cameras do not allow to visualize the structures located deeper than 4-6 millimeters, we had worked out the control method, which is as follows: all patients who underwent inguinal lymph nodes transfer we left monitor skin area to monitor the viability of the flap. One year after surgery skin paddle had surgically removed as lost its relevance thing. For all patients a year after the operation before removing the monitor skin area (40 minutes) we injected indocyanine green in the interdigital spaces intradermally After removing the skin site using photodynamic camera recorded that the lymph nodes rapidly
accumulating contrast, that clearly indicates their functional activity.

1. Miranda Garcés M., Pons G., Mirapeix R., Masià J. “ Intratissue lymphovenous communications in the mechanism of action of vascularized lymph node transfer.” J Surg Oncol. 2016 Nov 25.

2. Masia J., Pons G., Nardulli M.L. “Combined Surgical Treatment in Breast Cancer-Related Lymphedema.” J Reconstr Microsurg. 2016 Jan;32(1):16-27.

15:54 – 16:01h:

Name: A. Stritar
Organization: University Medical Center Ljubljana, Slovenia
Paper title: The use of a dermal regeneration template for total subcutaneous excision of lymphoedema

The use of a dermal regeneration template for total subcutaneous excision of lymphoedema

Stritar A., Grilc O.
Department of Plastic Surgery and Burns, University Medical Centre Ljubljana, Slovenia

Abstract: In the last two decades some new surgical methods for lymphoedema treatment are being used in plastic and burn reconstruction surgery.

As physiological operations we have experiences by lymphatic reconstruction, when a new lymphatic tissue is microsurgically implanted into lymphoedematous limb. While for ablative surgery, we usually perform a liposuction or total excisions using dermal regeneration template (DRT).

Total subcutaneous excision, originally described by Charles (1912) and commonly used since then, this operation is an extensive procedure that removes all of the skin, subcutaneous tissue – except in the foot and region overlying the calcaneal tendon – and deep fascia. The bared muscle is covered by split or full thickness grafts. Although split thickness grafts are technically easier in comparison to full thickness graft and initially appear satisfactory. Late scarring is marked and the grafts ulcerate and develop a severe hyperkeratotic, weeping, chronically infected dermatitis. Long-term postoperative results are bad with substantial scarring and lymphatic fibrosis.

We operated 7 patients by DRT usage in the last 5 years. They underwent an ablative surgery of subcutaneous tissue of a lower leg. After debridement a dermal regeneration templates (DRT) were used to cover exposed area. Grafts where protected by foil dressing and secondary dressing. After nearly 3 weeks, silicon layer was peeled off and neodermis was covered with autologous split thickness skin grafts. All the surgery and dressings were done according to producer’s guidelines orders. In two cases DRT was covered with split thickness skin graft during primary surgical procedure.

No infection or inflammation was found and primary ingrowths of templates were present, as also of skin grafts. Some areas showed granulation tissue in- between grafts. Later, skin cover showed a suitable result, without a moose like appearance. After six weeks patient started to wear elastic hoses.

Simple skin grafting represents unstable epithelial layer, while using DRT represents better quality of a skin cover. In chronic, long-standing lymphoedema where there is a substantial element of an extensive fibrosis, this may be the best technically feasible procedure available.

16:02 – 16:09h:

Name: P. Myshentsev
Organization: Samara State Medical University
Paper title: The combined application of complex of antioedematous therapy and surgical treatment of patients with lymphedema of lower limbs

The combined application of complex of antioedematous therapy and surgical treatment of patients with lymphedema of lower limbs

Myshentsev P., Katorkin S.
Samara State Medical University, Samara, Russia

Abstract: There was made an observation of 22 patients (19-64 years old) with lymphedema of lower limbs, who received surgical treatment during complex of antioedematous therapy. Stage I, II and III of disease had 2, 16 and 4 patients respectively. During pre-surgery period they had intermittent pneumatic compression, magnetotherapy, gravitational therapy (Russian patient #2441635, 10/02/2012). Lymphoveinous shunting operations were performed for: 4 patients with primary lymphedema and with signs of hypoplastic proximal lymphatic vessels; 18 patients with secondary lymphedema of mainly post-traumatic nature. Gravitational therapy course (5-7 sessions; 8-10 minutes on each) was given again beginning with the 5th day of post-operational period.

Complex treatment led to disappearance or reduction of heaviness and bloating in the affected limbs of all patients; the decrease of limb perimeter for 12-15% in 13 patients of I and II stages. Ultrasonic scanning of soft tissues limbs showed: changes of structure (disappearance or reduction of hypoechoic formations in the subcutaneous layer; no considerable changes of III stage patients (reduction of limb perimeters for 5%). Based on results of lymphotropic sample and lymphoscintigraphy there was improvement of lymphatic drainage resorption for 20-22% in 9 patients with I and II stages of the disease.

Thus, the efficiency of gravitational therapy for complex treatment of patients with lymphedema of lower limbs (in case of similar indications to lymphoveinous shunting) mainly depends on the stage of the disease. Provided that I and II stages of lymphedema (characterized by preservation of the structure of lymphatic vessels and soft tissues, and also by functionality of lymphangions), the stimulating effect on the lymph circulation is higher. With the increase of diffuse fibromatous reconstruction of soft tissues limb and with the decrease of perimeter of functioning lymph vessels to III stage of disease, the stimulation of lymphatic drainage with gravitational therapy is less effective.

16:10 – 16:17h:

Name: H. Winters
Organization: Radboudumc
Paper title: Lymphovenous Anastomosis and Secondary Resection for Noonan Syndrome with Vulvar Lymphangiectasia.

Lymphovenous Anastomosis and Secondary Resection for Noonan Syndrome with Vulvar Lymphangiectasia.

Mr. Harm Winters, Drs. Hanneke Tielemans, Professor. Dietmar Ulrich
Radboudumc, Nijmegen, Netherlands

Introduction: In this case report we describe the use of a 2-stage approach using lymphovenous anastomoses to treat severe recurrent vulvar lymphangiectasia in a patient with Noonan syndrome (NS). Lymphatic dysplasia is described to occur in up to 20% of patients with NS. Cutaneous lymphangiectasia is a benign disorder involving the dilatation of lymphatic channels. The lesions formed by these malformed channels can have a “frogspawn”-like appearance.

Patient and methods: A 25-year-old female patient with NS presented with major lymphangiectasia of both labia majora and minora. The patient was primarily concerned with the frequent oozing, itching, and severe pain the lesions were causing. The patient was treated previously 13 times in total without success. Surgery was performed creating 3 end-to-end LVAs. Thirteen weeks after LVA surgery, reconstruction was performed with advancement flaps of the labia majora, and wedge excision of the labia minora. The patient recovered without complications. At the 12-month follow-up, the patient was doing well. Although there were still some small vesicles on the left labia there was no more ooze, itch, and pain. Lymphatic mapping using indocyanine green showed improvement of the edema of her vulva region and patent LVA.

Conclusion: This case report is, to our knowledge, the first to describe this 2-stage approach in the treatment of severe vulvar lymphangiectasia. The treatment consists of creating LVAs followed by reconstruction of the vulva. In our opinion, adequate drainage facilitated by LVAs might eradicate the underlying cause of the lymphangiectasia and lymph edema thereby preventing recurrence after reconstruction of the vulva. The combination of LVA and secondary resection seems to be a therapeutic option in patients with these rare problems. In addition, this case demonstrates the benefits of preemptive LVA before performing surgery that may be at high risk for postoperative lymph edema.

16:18 – 16:25h:

Name: L. Tom
Organization: University of Washington; Seattle, Washington
Paper title: Axillary Vein Flow Velocity After Scar Excision During Vascularized Lymph Node Transfer: Preliminary Data

Axillary Vein Flow Velocity After Scar Excision During Vascularized Lymph Node Transfer: Preliminary Data

Laura K. Tom and Peter C. Neligan
University of Washington; Seattle, Washington

Analyzing the components of surgical interventions for lymphedema is necessary to fully understand the implications for the indications and outcomes for our lymphedema patients. To perform a vascularized lymph node transfer (VLNT), scar tissue is released from the impaired axillary lymph node bed and the main vein is dissected. As the vein is freed from the scar, any outside compression on the vein is relieved and this is visually evident. As the venous system and lymphatic system work in tandem, it is important to investigate this step of the procedure.

As a proof of concept study, our aim is to determine whether scar removal around the axillary vein at the time of VLNT affects venous flow velocities. Intraoperative venous flow velocities were measured with a non-invasive flowmeter probe after exposure of the axillary vein during planned VLNTs. Preliminary data includes a total of 15 patients with lymphedema duration ranging from 1 to 15 years, including 14 breast cancer patients and one melanoma patient. All had axillary lymph node dissection and radiation with the exception of the melanoma patient, who had only an axillary lymph node dissection.

Seven patients showed an increase in velocity with a mean increase of 50% and an absolute value increase of 37mL/min. One patient showed minimal flow both before and after the release, 4mL/min and 9mL/min respectively. Seven patients showed a decrease in flow with a mean decrease of 18% and an absolute value decrease of 29mL/min.

With this limited data, it is too early to draw any conclusion; however, the goal will be to characterize the axillary flow velocity changes to patient characteristics and clinical outcomes including bi impedance.

16:26 – 16:33h:

Name: J. Weissler
Organization: University of Pennsylvania
Paper title: Lymphovenous Bypass for the Management of Intractable Chylothorax in Infants: A Novel Surgical Approach to a Devastating Problem

Lymphovenous Bypass for the Management of Intractable Chylothorax in Infants: A Novel Surgical Approach to a Devastating Problem

Jason M. Weissler, MD[1], Martin J. Carney, BS[1], Peter F. Koltz, MD[1], L. Scott Levin, MD, FACS[1],[2], Suhail K. Kanchwala, MD[1], Stephen J. Kovach, MD[1]
1. University of Pennsylvania, Division of Plastic Surgery, Department of Surgery
2. Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA

Introduction: In the emerging field of lymphedema surgery, clinical initiatives have unveiled new avenues in support of novel microsurgical techniques. Pulmonary lymphangioectasia and traumatic lymphatic disease have traditionally been managed with obliteration of the abnormal lymphatic pathways through surgical ligation or catheter-embolization. [1-2] However, when traditional treatment modalities fail to achieve chyle leak resolution, opportunities for salvage have been dismal. To date, there have been no descriptions of microsurgical techniques in the algorithm for this devastating problem. Herein, we introduce a lymphaticovenous bypass technique for the management of persistent chylothoraces in infants.

Methods: A single-institution retrospective review was performed in effort to identify patients with clinically-significant persistent chylothoraces. Only patients who failed or were not candidates for embolization were included. Outcome measures included anastomotic patency, resolution of chylothorax, and complication-profile.

Results: Two patients met inclusion criteria, accounting for three operations. The first patient was a 6-week-old male who developed left subclavian vein thrombosis and thoracic duct occlusion following operations to repair his congenital-heart-disease (CHD). Given that the thrombus was not amenable to thrombolysis, and the development of bilateral pleural effusions, a lymphaticovenous anastomosis was performed between the thoracic duct and a small vein in the neck. Lymphangiography 1-week postoperatively revealed patent flow, resolution of chylous ascites, and near complete resolution of collateral flow. The second patient (4-month-old male) suffered a thoracic duct transection during cardiac surgery for CHD. He underwent a lymphaticovenous anastomosis between a lymphatic conduit in the neck and the external jugular vein, which subsequently became obstructed. A successful reoperation was performed 18-days later during which the vein was re-anastomosed to a larger portion of the thoracic duct. Lymphangiography at 2-weeks confirmed patent anastomosis.

Conclusion: Although thoracic duct embolization resolves chylothoraces in nearly three-quarters of patients, there remains a role for lymphovenous surgical bypass using microsurgical technique.

1. Itkin, M. Interventional Treatment of Pulmonary Lymphatic Anomalies. Techniques in vascular and interventional radiology 2016; 19:299-304.

2. Itkin, M., Kucharczuk, J. C., Kwak, A., Trerotola, S. O., Kaiser, L. R. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010;139:584-589; discussion 589-590.

BBM 2017 Free paper session

Friday, 17th March 2017. From 11:00h to 12:00h.

11:00 – 11:07h:

Name: M. Ermoshchenkova
Organization: The P.A. Herzen Moscow Cancer Research Institute
Paper title: Implant-based Breast Cancer Reconstruction with Biological Matrices and Synthetic Meshes

Implant-based Breast Cancer Reconstruction with Biological Matrices and Synthetic Meshes

M.V. Ermoshchenkova[1],[2], A.D. Zikiryahodjaev[1],[2] , I.M. Shirokikh[3],
V.I. Chissov[1],[2], A.Yu. Tukmakov[2], Baichorov E.A[4].
The P.A. Herzen Moscow Cancer Research Institute – the branch of the Federal State
1. Budgetary Institution «National Medical Radiological Research Center» at the Ministry of Health Care of the Russian Federation
2. The I. M. Sechenov First Moscow State Medical University
3. Russian University of People’s Friendship – RUDN University
4. Stavropol State Medical University

Abstract: Breast cancer accounts for 21,2% of malignant tumors of the female population in the Russian Federation. A radical subcutaneous and skin-sparing mastectomy is an alternative to radical mastectomy, which allows for primary rehabilitation if the selection of patients is correct. Biological matrices and synthetic meshes are to be used to replace autological flaps to protect a breast lower slope and to prevent an implant loss.

Materials and methods: From 2013 to 2016, 104 implant-based immediate reconstructive operations with mesh (N=80) and ADM (N=24) were performed in breast cancer patients after subcutaneous or skin-sparing, nipple-sparing mastectomies. The average age of patients is 47, 2 years old. Stage 0 was diagnosed in 2% of patients, I – 30%, IIA – 33%, IIB – 16%, IIIA – 15%, IIIB – 2%, IIIC – 2%. Titanium meshes were used in 12 cases and polyester 3D meshes in 68 cases. The size of Implants ranged from 120 to 585 sm3.

Results: Cosmetic result was rated as excellent in 67,3% cases, good in 19,2%, satisfactory in 7,7%, as very bad in 5,8%. The frequency of implant loss was 5,8% when titanium breast mesh was used and 0% with polyester mesh. Seroma was diagnosed in 1,9% when using pork ADM and 2,9% when using titanium mesh. Necrosis of a nipple was in 1,9% when using titanium mesh. Infection of the implant was recorded in 2,9% cases. A capsular contracture developed in 5,8% cases after radiotherapy.

Conclusions: Biological and synthetic materials are significantly important options for breast cancer reconstruction. They are adequate substitutes for autologous muscle flaps if a correct patient selection has been conducted. These operations require less time are less traumatic than those with flaps. The use of these materials allows to obtain good and excellent results in most cases.

11:08 – 11:15h:

Name: G. G. Caputo
Organization: AOUI Verona
Paper title: Single stage implant-based breast reconstruction in gigantomastia with a novel muscle-sparing technique.

Single stage implant-based breast reconstruction in gigantomastia with a novel muscle-sparing technique

Caputo Glenda G., Marchetti A., Pardo C., Vigato E., Governa M.
Azienda Ospedaliera Universitaria Integrata di Verona

Background: Skin-reducing mastectomy allows a single stage breast reconstruction with silicone implants in large and ptotic breasts [1,2]. However, the sub-muscular placement of the implant may trigger discomfort for the patient. We modified this technique for single-stage, implant-based breast reconstruction, combining an inferior pedicle dermal flap and the use of acellular dermal matrix, with complete pectoralis major muscle preservation [3].

Methods: from March 2014 to May 2016, 36 patients with breast cancer (8 bilateral) were selected for skin-reducing mastectomy. Surgery was performed according to the Wise-pattern-technique and implants were placed above the pectoralis major muscle in a pocket made by the de-epithelialized dermal flap in the lower pole and the acellular dermal matrix in the upper pole. The chest physical well-being was assessed in the follow-up period (minimum 6 months) through the BREAST-Q score [4].

Results: The technique proved to be easy, reproducible and fast (mean operative time: 124 min). The medium size of anatomical implants was 412 cc. In 12 patients a controlateral procedure was performed at the same time for symmetrization. Minor complications were observed in 4 cases. No implant loss occurred in the series. Analysis of BREAST-Q scores post-reconstruction, compared with pre-operative perceptions, showed a statistically significant higher level of satisfaction in many domains.

Discussion: Skin reducing mastectomy-muscle sparing reconstruction proved to be a useful alternative in those oncologic patients affected by gigantomastia. Pectoralis major muscle’s sparing reduced morbidity, postoperative pain and recovery time and gave an excellent cosmetic result without evidence of early major complications and with the improvement of the quality of life. Moreover, due to be a single-stage procedure, patients have at the same time demolitive and complete reconstructive surgery and can even have benefits from the breast reduction.

1. Patients with large and ptotic breast: Oncological and reconstructive results. Breast 2012;21:267–271.
2. Salgarello M, Barone-Adesi L, Terribile D, Masetti R. Update on one-stage immediate breast reconstruction with definitive prosthesis after sparing mastectomies. Breast 2011;20:7–14.
3. Caputo G., Marchetti A. and al. Skin reduction breast reconstruction with pre-pectoral implant. Plast Reconstr Surg 137: 1702, 2016.
4. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plastic Reconstr Surg Aug 2009; 124(2):345e53.

11:16 – 11:23h:

Name: V. Vindigni
Organization: Clinic of Plastic Surgery – University of Padova
Paper title: Breast reconstruction: how to choose the reconstruction strategy, a lesson from European School of Microsurgery

Breast reconstruction: how to choose the reconstruction strategy, a lesson from European School of Microsurgery

Vincenzo Vindigni, Carlotta Scarpa, Tito Brambullo, Franco Bassetto
Clinic of Plastic and Reconstructive Surgery, Padua University School of Medicine, Italy

Objective: The goal of the paper is to provide a simple guide to choose the most appropriate treatment for the reconstruction of the irradiated breast. This can be useful to give the young surgeon an overview of the reconstructive methodologies tailored to the type of patient and the available resources.

Design: A retrospective chart review was conducted of all irradiated breasts underwent reconstruction from 2010 to 2013 (n=90, 65 patients underwent primary breast reconstruction (group A) and 25 secondary breast reconstruction (group B). For all the patients we analyzed the timing of reconstruction related to RTx, the preoperative conditions as the story of the disease (the oncologicl risk), the local condition as the quality of the irradiated skin, the patient condition (e.g comorbidities and psychological aspects) and the local resources (e.g. the presence of microsurgical team). We also considered the kind of surgery performed and the complications.

Results: The group A: 35 patients who sought breast surgery after mastectomy plus radiotherapy: 29 received breast implant and 6 underwent autologous reconstruction. 25 patients performed the surgery before Rtx ad 5 required correction of breast conservative therapy related deformities.

The group B: 25 patients who required secondary surgery: 20 received autologous tissue (flaps or fat graft) and 5 removed the previous implants for polyurethane ones.

Conclusions: A careful analysis of our experience has shown the need to customize the reconstructive treatment depending on the features of the patient as there is no single treatment highly recommended for all irradiated breasts. In our study, we also noticed that the use of new therapeutic strategies may provide a useful approach or support, and finally, we noted that the role of microsurgery is still essential especially to correct deformities secondary to previous reconstructions or the outcome of radiotherapy.

11:24 – 11:31h:

Name: E. Eldib
Organization: Tanta University Hospitals
Paper title: Custom made flaps for breast reduction in severe macro-mastia using Doppler ultrasound for detection of perforator vessels

Custom made flaps for breast reduction in severe macro-mastia using Doppler ultrasound for detection of perforator vessels

Elsayed Eldib
Tanta University Hospitals

Abstract: Brest reduction in severe macro-mastia remains controversial. Most of plastic surgeons prefer free NAC graft technique to avoid nipple necrosis, however this technique has also disadvantages like graft failure, decreased sensation& breast projection and hypopigmentation.

The results of use of classic pedicled techniques in severe macro-mastia are also unpredictable and necrosis of the NAC can occur due to lack of blood supply.

Recent studies about blood supply of the breast clarifies that each patient has her Owen blood supply as regards the dominant vessels and the perforators.[1].

Methods: In this study 15 patients with sever macro- mastia with a mean age of 39 years ( range 35 to 58 years) were included in this study. Mean body mass index was 34 Kg/m2 (range 28 to 55 Kg/m2). Patients were followed up for 12 mnths (range 6-12 months). Major blood supply to NAC were determined by 8 to 10 MHz probe Doppler ultrasonography before surgery. Pedicles were designed according to vessel locations and the reduction were performed superomedial , superolateral, or septum based design.

Results: Non of the patients in this study had areola necrosis. Mean reduction weight was 1225 g per breast.

Conclusions: Ultrasonographic detection of the main perforators before designing the flap for breast reduction can help to save NAC from necrosis.

11:32 – 11:39h:

Name: V. K. Shankhdhar
Organization: ACTREC, Tata Memorial Centre, Mumbai
Paper title: Breast Oncoplasty: An Indian Scenario

Breast Oncoplasty: An Indian Scenario

Vinay Kant Shankhdhar, Prabha Yadav, Dushyant Jaiswal
ACTREC, Tata Memorial Centre, Mumbai, India

Aims: Breast conservation surgery is on the rise and after such excisions the remaining breast needs to be recontoured to maintain its shape and beauty. Breast reduction can be used as volume displacement method for oncoplasty if remaining breast has sufficient bulk.Indian women have moderate sized breast hence reduction procedures are possible for oncoplastic reconstructions even after relatively big tumour excisions. The reduction procedures are planned in such a way that the tumour lies in the part to be reduced.

Materials and Methods: All consecutive Breast Conservation Surgery patients from 2011-2016 operated in the Plastic Surgery Unit were included in this study. Fifty seven underwent Oncoplasty with reduction of opposite breast.Most common were upper outer quadranttumors,followed by lower outer quadrant, and central quadrant tumors.

Most commonly used technique was Superomedial(82.6%), followed by Inferior(10.14%) while Medial pedicle andVerticleBipedicleoccasionally.In12 patients local tissue readjustment procedures, mostly using inferior quadrant breast tissue was done.

Results: Skin necrosis in 8 patients which required debridement, vertical limb gape requiring secondary suturing in 2 patients, seroma in 2 patients and NAC necrosis in 1 patient.

Discussion: The procedures for breast oncoplasty range from local tissue adjustments to reduction mammoplasty procedures depending on the proportion of the tissue excised.

Conclusion: Cosmesis of the breast can be preserved in modertate sized breasts even after big tumour resections using principles of reduction mammoplasty.

11:40 – 11:47h:

Name: B. Celet Ozden
Organization: Istanbul univ. Istanbul Medical Faculty Dept of Plastic and Reconstructive Surgery
Paper title: The Use of Bovine Pericardial Graft as ADM Alternative In Reconstructive and Revisional Breast Surgery

The Use of Bovine Pericardial Graft as ADM Alternative In Reconstructive and Revisional Breast Surgery

Burcu Celet Ozden
Istanbul University, Istanbul Medical Faculty, Dept of Plastic and Reconstructive Surgery

Introduction: In the last few decades, there has been a growing demand for soft tissue replacements in both esthetic and reconstructive breast surgery. Although many types of synthetic meshes and biological grafts have been proposed, acellular dermal matrices (ADM) have become the gold standard to be used in this setting. However, high costs have prevented the liberal use of ADMs in many countries.

Tutopatch®, generally used for abdominal wall reconstruction or neurosurgery is made of acellular bovine pericardium that contains high amount of collagen facilitating fast healing and tissue regeneration. Although the biologic properties and in vivo behavior is very similar to ADMs, it is available in much bigger pieces for lower costs. We used this product as an alternative to ADM in immediate direct to implant (DTI) breast reconstruction as well as esthetic breast revisions.

Patients and Methods: Tutopatch® was used in DTI breast reconstruction in 13 patients (20 breasts, 19 partial subpectoral, 1 prepectoral pocket), and in revisional breast surgery in 4 patients (1 correction of animation deformity, 1 capsular contracture revision and 2 symmastia repairs).

Results: Median (range) postoperative follow-up was 6 months (6 weeks-18 months). There was no mastectomy flap/NAC necrosis, infection, seroma or implant loss in the early postoperative period. There was one patient who developed red breast syndrome that healed uneventfully in 8 weeks. One patient underwent postmastectomy radiotherapy and completed without any complications.

Discussion: There is ongoing search for an ideal soft tissue substitute to be used in breast surgery. Although the use of bovine pericardium has previously been reported in only one case of breast reconstruction [1], we believe it is an ideal material due to its lower cost, and nonantigenic, noninfectious properties as well as soft tissue consistency that is very similar to ADMs. However, as in any biologic product, it does have a learning curve and nonselective use may cause an increase in product related complications.

1. Semprini G, Cattin F, De Biasio F et al. “The bovine pericardial patch in breast reconstruction: a case report” G Chir. 2012; 33 (11-12): 392-4.

11:48 – 11:55h:

Name: Y. Bachour
Organization: VU University Medical Center, Amsterdam, the Netherlands
Paper title: Poly Implant Prothèse Silicone Breast Implants: Implant Dynamics & Capsular Contracture

Poly Implant Prothèse Silicone Breast Implants: Implant Dynamics & Capsular Contracture

Y. Bachour1, MD, Z.C.M. Heinze[1], BSc, T. Dormaar[2], MD, P.H.J. Keizers[3], PhD, W.G. van Selms[2], MD, M.J.P.F. Ritt[1], MD, PhD, F.B. Niessen[1], MD, PhD
1. Department of Plastic, Reconstructive and Hand Surgery, VU University Medical Center,
Amsterdam, the Netherlands.
2. Onze Lieve Vrouwe Gasthuis (OLVG Hospital), Amsterdam, The Netherlands.
3. National Institute for Public Health and the Environment, Bilthoven, The Netherlands.

Background: The Poly Implant Prothèse (PIP) implants were withdrawn from the market in 2010 due to the use of low-grade silicone, causing a high risk for implant rupture [1-3]. This resulted in a large number of asymptomatic women undergoing reoperation.

The aim of this study was to investigate the implant dynamics of PIP breast implants.

Additionally, to determine the rate and predictors of implant gel bleeding and rupture, as well as the rate and predictors of capsular contracture in PIP implants.

Methods: Eighty women with 152 PIP implants underwent a reoperation in 2012 and were enrolled in this study. Physical investigation was performed and the Baker score was determined while demographics were retrospectively traced in medical records. The pre- and post-operative volume of the implants were measured or calculated, and their state was determined by the surgeon during the operation.

Results: Physical examination showed capsular contracture in 13.6% of the women. There was gel bleed in 42% of the implants and rupture in 25% of the cases. Furthermore, in intact implants there was a post-operative increase as well as a decrease seen in the mass of the implants. There was a correlation between gel bleeding implants and the increasing of the post-operative implant volume. Capsular contracture could have a protective effect against post-operative implant volume increase, while a post-operative implant volume increase could also provide a protective influence in developing capsular contracture. Additionally, the rupturing of implants led to a higher susceptibility of capsular contracture.

Conclusion: We managed to illustrate that PIP implant shells might have been to permeable. Also that there is a correlation between gel bleeding and increase of the post-operative implant volume. Capsular contracture and post-operative implant volume increase had protective effects on each other. Finally, the rupturing of implants led to a higher risk for developing capsular contracture.

1. AFSSAPS. Topical report PIP silicone gel pre-filled implants. 2010. Accessed 20-10 2016.
2. Swarts E, Kop AM, Nilasaroya A, et al. Rupture of poly implant prothèse silicone breast implants: an implant retrieval study. Plastic and reconstructive surgery. 2013;131:480e–489e.
3. Maijers M, Niessen F. Prevalence of Rupture in Poly Implant Prothèse Silicone Breast Implants, Recalled from the European Market in 2010. Plast Reconstr Surg. 2012;129:1372.

11:56 – 12:03h:

Name: W. Yi-Chia
Organization: Department of Plastic Surgery, Kaohsiung Municipal Ta-Tung Hospital
Paper title: A Case-Series of Seroma in Prosthetic Breast Reconstruction in Asians

A Case-Series of Seroma in Prosthetic Breast Reconstruction in Asians

Yi-Chia Wu, Ya-Wei Lai, Feng-Su Chang, Fang-Ming Chen
Department of Plastic Surgery, Kaohsiung Ta-Tung Municipal Hospital, Kaohsiung, Taiwan
Department of Surgery, Kaohsiung Ta-Tung Municipal Hospital, Kaohsiung
Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Background: Seroma in immediate prosthetic reconstruction after mastectomy occurs frequently. Progression of seroma result in early prosthetic failure due to mastectomy flap necrosis and/or infection [1,2]. The managements of postoperative seroma are very important.

Methods: A review of 75 consecutive breasts undergoing immediate prosthetic
reconstruction between Aug. 2014 – Jan. 2017 was conducted. The drain was removed when the amount was less than 20cc/day. Prophylactic antibiotics were prescribed once the seroma was detected. Aspiration of the seroma was performed once or twice a week. The impact of seroma on postoperative course, and the seroma-related events were recorded.

Results: The overall seroma rate was 8%. There were 1 prosthetic loss, 2 infections, and 1 revision surgery among the 6 cases. Capsulectomy was performed in the patient who developed mastectomy flap necrosis and infection. The prosthesis replacement with tissue expander and quilting stitches were performed in the other revision surgery.

Discussion: The progression of seroma increased the risk of prosthetic failure resulted from mastectomy flap failure and concomitant infection. Adequate drainage placement, pocket formation for the prosthesis, and meticulous hemostasis might be the keys for seroma prevention. The prompt managements of the seroma in our series including aspiration, compression, prophylactic antibiotics use, and surgical intervention.

1. Risk Factor Analysis for Capsular Contracture, Malposition, and Late Seroma in Subjects Receiving Natrelle 410 Form-Stable Silicone Breast Implants (Plast. Reconstr. Surg. 139: 1, 2017.)
2. Seroma in Prosthetic Breast Reconstruction (Plast. Reconstr. Surg. 137: 1104, 2016.)