Surgery Spotlight: Breast Reconstruction and Treatment of Lymphedema-Surgery Spotlight: Breast Reconstruction and Treatment of Lymphedema

Surgery Spotlight: Breast Reconstruction and Treatment of Lymphedema

Video Transcription

My name is Jaume Macià, I am a professor in plastic surgery, chief of the department of plastic surgery in Sampao Hospital.  Our hospital is one of the five university hospitals in Barcelona and that is a special  place because this is the oldest active hospital in Europe, 700 years of history doing medicine in Europe.  With this place, our department was one of the pioneers in southern Europe, starting with the perforator flap concept and the case that we are going to do today is a combination  of two things, perforator flap surgery and lymphatic surgery.  It's a very interesting case because it's a patient that has on the left arm has developed  a lymphedema, on the right hand, on the right limb, that has no lymphedema, but we are going to do a prophylactic lymphedema surgery.  It's a bilateral delay reconstruction, so what we are going to do is a bilateral DAP with bilateral lymph node transfer and on the lymphedema side, we are going to do also  lymphovenous anastomosis. It's a very long operation, it's nice because we need to combine different concepts about  what is lymphedema surgical treatment and what is perforator flap concept, also DF flap, CF flap concept and in fact it's like four surgeries in one case.  This is the case that we are going to do today in our theatre. It's a very interesting case because this is a bilateral brace reconstruction with a unilateral lymphedema.  It means that it's going to be conventional DAP reconstruction on the right side and on the left side is going to be what we say TATIVAR, total brace and atymum restoration, but in  fact what we are going to do here is also we are going to try and explore the lymphatic system in order to make what they say a prophylactic lymphedema surgery.  Also the case is not only interesting because it's a bilateral case and one-sided, also the history of the lymphedema is quite infrequent.  The lady had first a breast cancer on the right hand. She had modified radical mastectomy and radiotherapy.  You can see here the spots of the radiotherapy come and on the arm it was nothing wrong. It was normal from 2009 and in 2013 the lady felt something wrong on the breast.  They make a kind of assessment, an imaging assessment, and they found a little tumour on the upper external quadrant and also two metastases on the lymph nodes.  Then they decide to do a neoadjuvant chemotherapy and in the second cycle she starts the lymphedema.  This is very infrequent but from time to time you have patients that when they have a metastatic  ganglion impairment and also they start with the chemotherapy, they develop a lymphedema. The lymphedema, you can see the difference between the two arms, especially in the forearm  and the elbow a little bit on the proximal part of the arm, is that the difference is about two centimetres and she's taking care very well of the lymphedema and still you  can see the arm is quite soft because she's wearing a garment and she's doing quite a good exercise.  But our objective is just in one operation to do bilateral breast reconstruction, treatment  of the lymphedema on the left side and prophylactic treatment of the lymphedema on the right arm.  When you have a bilateral breast reconstruction it's more difficult because we need more tissue, it's more work, but also because we have lost completely the footprints of  the normal breast. We don't have any reference, only we have here the scars, here you have a scar of the  mastectomy that you see this is a horizontal scar of the mastectomy and then we need to recreate everything and we need to do all symmetrically.  And we have here also a big difference, this is a normal tissue because it's fresh tissue, never received rheotherapy and this area, big area, you can see that the rheotherapy  fill, it arrives until two fingers above the umbilicus, it's a big area. And also this tissue even, it looks like okay, never is the same, this is better vascularised  and this is always more fibrotic and it's pretty different. We are going to mark here the scars, this is the mastectomy scar, these dots because  she has a very good, you know, scar, good healing, that is good, you know, you can see that arrive from here to here and this is the previous one that has been under the effect  of the rheotherapy. This in fact is arriving until here, until the apex of the axillary pyramid. And now you can put down, blue colour.  The first thing is always midline, body midline because we need to, what we do, we need to try to do symmetrically and then it's the fossa jugularis, we are going to look for  the, what is this term, xiphoides apex, this is like here, and then we are going to try to make this midline, you can keep here, this is midline axis, we are trying to recreate  the normal, you know, nipple, thorax line, and then we are going to try to put a line like this, about 8, 11, probably 8 here and 8 here, this level, then we are going to try  to recreate.  And this lady is not very tall, then it means that... ¿Cuánto mides? Unos cincuenta y cuatro. You can keep like this. It's more or less we are going to put here.  It's going to be the place of the... at this level. It's going to be where the nipples should be. More or less midpoint ten. Seven, seven, okay. That is going to be the nipple.  More or less, good, good, good, good. And then we are going to try to recreate...  And then symmetrically we are going to get it like this.  This is going to be the infirmary fold. Now that area is going to be the infirmary fold. This is going to be the infirmary fold. This is going to be our donor site that you see.  It looks like it's not too much tissue, but it's like always. In Europe, most of the patients, they are like this lady. They are not very fat women.  Normally, we used to deal with this kind of abdomen. It's a little bit bigger, but not so big like in some other places in the world.  But when there's a lady like this, she's 40-something, always you can take enough tissue to make a small breast.  The thing is we need to check how much you can take in order to close and also in order to put as low as we can the incision  because the nice thing is not put here in the middle of the abdomen, the scar. It's always to put the scar in a nice place under the bikini line.  And then in that lady, we are going to try to take all of this tissue and put more or less at this level the scar. We make this drawing. This is a coordinate axis.  We are going to transfer the information from the CT scan to the body of the patient. Here on this right DAP, the best perforator is in X, 1.3X and 1.5Y.  It's more or less at this level. This is going to be the best perforator of this part of the abdomen. And on the other side is 2.6 and 1.5.  It's going to be at this level, the best one. And there is also the second one that is quite good too. This is 4.5 and here, quite close.  Once we have the perforators, we are going to let the melatonin. We are going to just redo and to make the design of our flap.  We need to try to put the perforator with tissue enough to be sure that this perforator is going to keep all the branching inside the tissue.  But we need to put our cranial incision as low as we can because we want to put the caudal one as low as we can because we need to keep everything under the bikini line.  This is why we are going to do more or less like this. This is going to be our flap design.  We are going to take this level that is going to be under the bikini line. We are going to do exactly the same as a mirror on the other side  to get a symmetrical shape of the abdomen. And then we are going to do like this, more or less.  Now, once we have transferred the information from the CT scan, I like to do always a double checking in two ways. One, I am going to check where is exactly the superficial system  and I also like to listen how is the sound of my perforators. What we are going to do now is what I said, we are going to recheck by the ultrasound doppler, the most simple device.  We are going to check the superficial system and also how are our perforators.  This is one from the right side of the abdomen.  This is the other one from the left side. It sounds stronger. But I think both are very similar.  What now we are going to check is the superficial system. The superficial system, you must remember that it is an axial system.  Then it is much easier to follow and to study with the doppler.  This is the superficial epigastric artery, that even you can follow going down and you can know exactly the direction. And this is the superficial circumflex iliac artery.  The same from the other side. You can see the vein with the artery. Another vein.  And another artery. You can see everything on the left part is stronger. This is part of the anatomy variability. This is going to be our perforator from this side.  This is the perforator from this side.  This is the second one. It is very close. Always it is nice to mark just in case. This is going to be the superficial circumflex iliac artery.  And this is going to be the epigastric superficial. The same like this.  And now we are going to mark the lymph nodes. We check with the CT scan exactly where are the superficial epigastric lymph nodes in order to avoid to move down to the inguinal area  and to have a problem and develop a secondary lymphedema. That is very important.  On the right hand is 13 levels from the umbilicus and 9.5 cm. At this point there are 2-3 nice lymph nodes that we are going to include in this flap.  And on the other side is a little bit more medial. It is at the same level. It is 7.5 cm. It is here.  Normally if you know where they are, they are always in the middle of the vessels. That is important. Give me the red color.  And then it means that we are going to dissect these vessels. Include this and then normally what we can see is like this. Taken like this.  Going to here until the femoral vessels. All of these lymph nodes that we are taking here, when you take that, you don't have any risk to develop any lymphedema on the lower limb.  And also it is very important that you don't take these lymph nodes isolated. This is a new concept.  Potentially to increase this lymphogenetic function or even the weight for sucking all of this lymph that you have there, you need to keep all this tissue around like this.  All the tissue include here. It means this is going to be all the fat that we are going to include with the lymph nodes. Why am I keeping it in a piece?  Because at this area you have many physiological lymphovenous anastomosis. But inside here it means that from this area you can suck part of the lymph  and put on the vein system on this superficial area. What we are going to do now is we are going to do an ICG assessment with the Flubeam  in order to see how is working this arm and how is working this arm and to make that. This is ICG dye. What we are going to do is always checking both arms,  the affected one, the lymphedema, and the non-affected. What we do is we put a very small quantity. It's like 0.2 with the second in the digital space like this.  This is not painful for the patient. It's very small like this.  And then normally I have here and with the same here.  We do exactly the same in the normal one to compare how is the lymphatic system. Because also in the lymphatic system there is a very high variability  and not everybody has the same distribution of the lymphatic channels and the same number and everything. Now I always ask to the patient just to open and close the hands  and also if they know how to dance flamenco you can do a little bit of flamenco. This is Spanish atmosphere and this is important.  And now the first after that is the first checking. It's really important to be the first one. You can see that how fast it's going up. This is not the good one.  Let's go to see the good one, the normal one. You can see the normal one even is slower. It depends. And then what we are going to see, this is important. Are you recording? Record.  Are you recording now? Are you sure?  You can just make this first assessment and check that there is nothing here. You can see the normal one. Nothing here. Only that.  If you see, I'm going to show you only a little bit because I don't like to do that. This is what some people do. You make some little pressure here.  You can see how it goes up faster. But I don't like to do that. I like to wait for the natural system to move. Okay, this is five minutes later after these flamenco movements.  And we can see here, you can see now, the lymphatic channels going up. Here you have an area of dermal back flow. This is where it's going up.  Here you have an area of dermal back flow. This is where the lymphedema area is. Okay. And what is important to see is just to see the axial line. You can see here again.  I told you that the lady has mainly the lymphedema is elbow and kind of the proximal part of the arm.  And what we are going to do now is to mark which are still the active lymphatic channels.  Okay, this is the lymphatic channel going up. Going up.  Going up.  Okay. Here you have another one.  This is the area of the more or less...  the area from here to...  to see all of this area around...  Ok, this is the area around...  and is arriving until more or less...  this area...  because all of this area is the area of the lymphedema. Okay, and let's go to see the other side,  the normal one, you can see.  Give me your hand.  This is going, going up, going up, nothing here.  And now let's go to see the axial area. You can see here one spot and you can see some lymphatic channels, you can see, going from behind.  She has a little bit of lymphedema sign here, you can see.  This is lymphatic channel, but here is some dermal backflow,  and some more dermal backflow. You can see, clinically, the lady has not lymphedema, but she's starting developing some kind of signs of lymphedema.  This is why what we are going to try to look in that lady  is to find the lymphatic channels that still, they are not completely fibrotic, they are still functional. Give me the verde.  And here you have, these are good.  This is in fact the line, okay.  But this is the area that she has some kind of,  let's go to see the autofocus, maybe it's too light. Yeah, you can see very well.  Okay, above the affected area,  one spot here, one little spot here, like 0.1.  And one little spot here.  Okay, I'm going to put here only two spots.  Okay.  Dermal backflow.  Now we are going to see if there is something going to the axilla.  You can see the dermal backflow is going up.  But there is no transmission at all here. But I am checking if there is any lymphatic channels still going to the axilla. But you can see that is what Koshima explained,  that the fibrosis, the sclerosis of the lymphatic  is from the obstructional point to the distal area.  It means that all of this area is completely stopped.  And also she has not any, another thing to observe is she has not any dorsal pathway.  Normally there are some dorsal pathway here, some people, and this is why she developed lymphedema. She had only medial pathway, and this is completely affected.  The other one, you can see that here you have  little bit starting to running, okay? You can see these ones.  Okay, that's good. No active lymphatic channel until here. Could you say that one more time? Okay, what we can see in this arm, the arm that is affected,  mainly the main area is that. But in fact it's all affected from here to here. It's because here is the obstruction of the lymphatic system. There are no dorsal pathways.  And all of this lymphatic area, lymphatic channels is completely stopped. It's not working. Only they are still remaining functional, this area.  What we are going to do here is to do LBAs at this level. Okay? Here and here. And probably here another one. We are going to do LBAs and ostomosis.  And then transfer all the tissue here, the lymph nodes, the breast and everything. Here is different. Here she has still remaining functional lymphatic channels.  What we are going to do, we are going to look for this one. Probably they are going to need more time to arrive here.  And then here we are going to do the lymphatic lymph node transfer with lympholymphatic and ostomosis. Okay?  But we saw on the ICG assessment that even if this arm looks normal, at this area she already had some damage because she had already some dermal backflow. This is a blue pattern 5.  This is the dye that is for the lymphotropies. And we are going to put two spots. One here. Now take a picture here.  Another here just beside the sun.  And the last one we are going to put here.  Hi again. As we told at the beginning, before to start the surgery, we already finished, everything is fine. We did what we wanted. We did on the right upper limb, we did the  lymphoid anastomosis distally in the most cranial place where the lymphatic channels still remain active. We made the left reconstruction with the contralateral DAP and the lymphoid  transfer. And on the right part, we did breast reconstruction with the left abdomen with  the DAP system. We made a prophylactic lymphoid transfer at that area, both sides with double  vascularity. It means that independent vascularity for the lymph nodes, independent vascularity  for the flap. It has been a very interesting surgery because we saw how difficult is sometimes  to manage the axillary receptor vessel after surgery and after rheotherapy. We also saw how one flap can stop even if the artery looks okay because sometimes when you combine two  flaps, you miss some little things like keeping the right temperature or keeping the blood pressure or the cardiac output high. All of these things we have shared with you. I  think this is a good case because we can learn from many points of view. The most important thing is at the end the patient is fine and our surgery, it looks fine at least until  now. Thank you very much.  www.ottobock.com

Video Summary

Dr. Jaume Macià, a professor and chief in plastic surgery at Sampao Hospital, discusses an intricate surgical case involving a combination of perforator flap and lymphatic surgeries. The hospital, recognized as one of the five university hospitals in Barcelona and the oldest active hospital in Europe, undertakes this complex procedure—a bilateral breast reconstruction and treatment for unilateral lymphedema. The patient, initially diagnosed with breast cancer, had undergone a mastectomy and radiotherapy. She later developed lymphedema on her left arm due to chemotherapy for metastatic tumors. This surgery involves a bilateral DAP (Deep Inferior Epigastric Perforator) flap, bilateral lymph node transfer, and lymphovenous anastomosis for the affected side. During the surgery, Dr. Macià highlights the challenges of recreating breast symmetry post-mastectomy and addressing tissue differences caused by prior radiotherapy. The team employs advanced techniques, including ICG (Indocyanine Green) assessment and customized flap designs, ensuring careful consideration of lymphatic health. Ultimately, the surgical team successfully completes the procedure, emphasizing the importance of maintaining precise conditions for optimal outcomes.

Asset Caption

This Surgery Spotlight will provide an in depth look at breast reconstruction and treatment of lymphedema using lower abdominal flaps harvested with attached inguinal lymph nodes performed by Dr. Jaume Masia of Sant Pau University Hospital in Barcelona, Spain.

Upon completion of this video, you should be able to:

Identify pre-operative site markings for: bilateral breast reconstruction, placement of nipples, perforator flap incision, superficial circumflex iliac arteries incision, inguinal lymph nodes and surrounding area incision, and active lymphatic channels.
Explain the importance of using indocyanine green (ICG) to visualize lymphatic flow of lymphatic channels.
List tips and techniques to ensure successful breast reconstruction via perforator flap surgery.

Faculty: Jaume Masia, MD

Keywords

Jaume Masia MD

surgery spotlight

surgical video

breast

reconstruction; Memben

plastic surgery

perforator flap

lymphatic surgery

breast reconstruction

lymphedema treatment

mastectomy

lymphovenous anastomosis

ICG assessment

customized flap designs