Kwon Jin Geun, Hong Dae Won, Suh Hyunsuk Peter, Pak Changsik John, Hong Joon Pio
Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
Arch Plast Surg. 2021 May;48(3):246-253. doi: 10.5999/aps.2020.02432. Epub 2021 May 15.
In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient's pathology, the treatment plan should be carefully decided and individualized. At the authors' institution, the treatment plan is made individually based on each patient's symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient's pathophysiology, optimal outcomes can be achieved. Depending on each patient's pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.
为了为乳腺癌相关淋巴水肿（BCRL）患者提供一种生理解决方案，外科医生必须了解淋巴水肿的病理发生部位及方式。基于每位患者的病理情况，应仔细制定并个性化治疗方案。在作者所在机构，治疗方案是根据每位患者的症状及相关因素单独制定的。大多数早期患者首先接受消肿治疗，然后根据治疗效果，建议采取手术方法。如果患者适合手术，需仔细检查所有淋巴液流动受阻的部位。因此，BCRL患者可考虑进行淋巴管静脉吻合术（LVA）、淋巴结皮瓣移植、瘢痕切除术或联合应用这些方法。LVA针对位于深脂肪层内的扩张浅表集合淋巴管，术前使用超声进行定位至关重要。如果腋窝存在挛缩，应进行腋窝瘢痕切除以减轻静脉压力并促进更好的引流。此外，切除瘢痕并重建脂肪层将为淋巴管再生提供更好的机会。在完全切除瘢痕组织后，进行区域脂肪瓣或带淋巴结转移的旋髂浅动脉穿支皮瓣移植。通过根据每位患者的病理生理情况制定BCRL的手术计划，可实现最佳治疗效果。应根据每位患者的病理生理情况，规划LVA、瘢痕切除、带足够脂肪皮肤瓣的血管化淋巴结转移以及同期乳房重建。
