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Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) for Lymphedema Prevention After Axillary Lymph Node Dissection A Single Institution Experience and Feasibility of Technique
Kelsey Lipman MD 1, Mardi Karin MD 2, Dung Nguyen MD 1 1 Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA 2 Department of General Surgery, Stanford University, Palo Alto, CA

Background: Breast cancer related lymphedema after axillary node dissection leads to decreased limb functionality and overall quality of life. While surgical options exist to treat lymphedema, lymphatic microsurgical preventing healing approach (LYMPHA) has been introduced as a preventive measure that can be performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. In this study, we highlight details of the operative technique and our postoperative experience.

Methods: Patients with breast cancer undergoing axillary lymph node dissection (ALND) with complete or partial mastectomy were offered LYMPHA prior to surgery. Circumferential limb measurements and personalized body composition analysis using bioelectrical impedance software (InBody, Biospace Co., Seoul, South Korea) were performed pre and postoperatively. Intraoperatively, all patients underwent axillary reverse lymphatic mapping with indocyanine green (ICG) and lymphazurin. SPY-PHI fluorescence imaging system (Stryker, MI, USA) was used to visualize uptake of ICG into lymphatic channels in the arm and track drainage into the axilla. The plastic surgeon worked concurrently with the breast surgeon to identify arm lymphatics that drained into the excised lymph nodes. These cut lymphatics were preserved for lymphaticovenous anastomosis (LVA). At completion of each microanastomosis, ICG was visualized draining from the arm lymphatic through the recipient vein. Patient data including demographics, operative details, complications, and long-term outcomes were recorded.

Results: A retrospective review identified eleven patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA procedure by a single plastic surgeon over the span of 16 months. The average age and BMI were 54 years and 24 kg/m2, respectively. The number of LVAs performed in each patient ranged from one to four per axilla. Operating time ranged 32-95 minutes. All patients received postoperative radiation therapy. There were no surgical complications, and thus far no patients have developed lymphedema with an average follow up of 7 months. Three patients endorsed decreased shoulder range of motion postoperatively, managed by physical therapy. At clinic follow up, ICG and SPY angiography were used to confirm intact linear lymphatic conduits with uptake of ICG across the axilla.

Conclusion: This study supports LYMPHA as a feasible and effective method for lymphedema prevention. It highlights the use of ICG and SPY angiography both intraoperatively and at follow up to confirm adequate lymphatic flow through the anastomoses. Early results at our institution remain promising, and long-term data will further determine its utility. In the future, it has the potential to become routine as an adjunct procedure to axillary dissection for breast cancer patients.

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