Publications by authors named "Dhruv Singhal"

89 Publications

Use of non-contrast MR in diagnosing secondary lymphedema of the upper extremities.

Clin Imaging 2021 Sep 10;80:400-405. Epub 2021 Sep 10.

Beth Israel Deaconess Medical Center, Department of Radiology, 330 Brookline Ave., Boston, MA 02215, United States of America. Electronic address:

Purpose: The purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema.

Materials And Methods: Upper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated.

Results: Of the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80-1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%-99.9%], and 75.0% [47.6%-92.7%], 87.5% [74.9%-94.3%], and 92.3% [63.1%-98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001).

Conclusions: DRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.
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http://dx.doi.org/10.1016/j.clinimag.2021.08.018DOI Listing
September 2021

Cost-Effectiveness Analysis: Lymph Node Transfer vs Lymphovenous Bypass for Breast Cancer-Related Lymphedema.

J Am Coll Surg 2021 Jun 5;232(6):837-845. Epub 2021 Mar 5.

Department of Surgery, Tufts Medical Center, Boston, MA. Electronic address:

Background: Lymph node transfer (LNT) and lymphovenous bypass (LVB) have been described as 2 major surgical options for patients with breast cancer-related lymphedema (BCRL) who have failed conservative therapy. The objective of our study was to perform a cost-effectiveness analysis comparing LNT and LVB for the treatment of BCRL.

Study Design: Rates of infection, lymph leak, and failure of LNT and LVB were obtained from a previously published meta-analysis. Failure of surgery was defined as the inability to cease compression therapy postoperatively. Procedural costs were calculated from Medicare reimbursement rates. Cost of conservative management of postoperative surgical site infection, lymph leak, and continued decongestive physiotherapy after failed surgery were obtained from literature review. Average utility scores for each health state were calculated using a visual analog scale survey, then converted to quality-adjusted life years (QALYs). A decision tree was constructed, and incremental cost-effectiveness ratio was assessed at $50,000/QALY. Deterministic and probabilistic sensitivity analyses were performed to evaluate the robustness of our findings.

Results: LNT was less costly ($22,492 vs $31,927) and more effective (31.82 QALY vs 29.24 QALY) than LVB. One-way (deterministic) sensitivity analysis demonstrated that LNT became cost-ineffective when its failure rate was more than 43.8%. LVB became more cost-effective than LNT when its failure rate was less than 21.4%. Probabilistic sensitivity analysis using Monte-Carlo simulation indicated that even with uncertainty present in the variables analyzed, the majority of simulations (97%) favored LNT as the more cost-effective strategy.

Conclusions: LNT is a dominant, cost-effective strategy compared to LVB for the treatment of BCRL.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.02.013DOI Listing
June 2021

Immediate Lymphatic Reconstruction: Technical Points and Literature Review.

Plast Reconstr Surg Glob Open 2021 Feb 17;9(2):e3431. Epub 2021 Feb 17.

Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, N.Y.

Recent studies have provided evidence that lymphovenous bypass-microsurgical re-routing of divided lymphatics to an adjacent vein-performed at the time of lymph node dissection decreases the rate of lymphedema development. Immediate lymphatic reconstruction in this setting is technically demanding, and there is a paucity of literature describing the details of the surgical procedure. In this report, we review the literature supporting immediate lymphatic reconstruction and provide technical details to demystify the operation for surgeons who wish to provide this option to their patients.
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http://dx.doi.org/10.1097/GOX.0000000000003431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7929616PMC
February 2021

Evaluating the Impact of Immediate Lymphatic Reconstruction for the Surgical Prevention of Lymphedema.

Plast Reconstr Surg 2021 03;147(3):373e-381e

From the Division of Plastic and Reconstructive Surgery and the Departments of Rehabilitation Services and Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Division of Surgical Oncology, Maine Medical Center.

Background: Breast cancer-related lymphedema affects one in five patients. Its risk is increased by axillary lymph node dissection and regional lymph node radiotherapy. The purpose of this study was to evaluate the impact of immediate lymphatic reconstruction or the lymphatic microsurgical preventative healing approach on postoperative lymphedema incidence.

Methods: The authors performed a retrospective review of all patients referred for immediate lymphatic reconstruction at the authors' institution from September of 2016 through February of 2019. Patients with preoperative measurements and a minimum of 6 months' follow-up data were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence.

Results: A total of 97 women with unilateral node-positive breast cancer underwent axillary nodal surgery and attempt at immediate lymphatic reconstruction over the study period. Thirty-two patients underwent successful immediate lymphatic reconstruction with a mean patient age of 54 years and body mass index of 28 ± 6 kg/m2. The median number of lymph nodes removed was 14 and the median follow-up time was 11.4 months (range, 6.2 to 26.9 months). Eighty-eight percent of patients underwent adjuvant radiotherapy of which 93 percent received regional lymph node radiotherapy. Mean L-Dex change was 2.9 units and mean change in volumetry by circumferential measurements and perometry was -1.7 percent and 1.3 percent, respectively. At the end of the study period, we found an overall 3.1 percent rate of lymphedema.

Conclusion: Using multiple measurement modalities and strict follow-up guidelines, the authors' findings support that immediate lymphatic reconstruction at the time of axillary surgery is a promising, safe approach for lymphedema prevention in a high-risk patient population.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000007636DOI Listing
March 2021

Establishing Standards for Centers of Excellence for the Diagnosis and Treatment of Lymphatic Disease.

Lymphat Res Biol 2021 02 5;19(1):4-10. Epub 2021 Feb 5.

Center for Molecular Imaging, McGovern Medical School, UTHealth, Houston, Texas, USA.

Lymphatic disease patients make up a significant proportion of the US and world populations. Due to inadequate medical school training and underestimation of the impact of lymphatic circulation, lymphatic disease patients often have difficulty finding competent diagnosis and care. The Lymphatic Education & Research Network has initiated a Centers of Excellence program to designate institutions that provide services for lymphatic disease patients. Committees of experts drafted standards for five types of Centers of Excellence. The Centers of Excellence program is now launched, and the description of the formation process herein could provide other organizations guidance for similar ventures.
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http://dx.doi.org/10.1089/lrb.2020.0022DOI Listing
February 2021

Axillary lymph node dissection in the era of immediate lymphatic reconstruction: Considerations for the breast surgeon.

J Surg Oncol 2021 Mar 1;123(4):842-845. Epub 2021 Feb 1.

Breast Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

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http://dx.doi.org/10.1002/jso.26355DOI Listing
March 2021

Breast Cancer-Related Lymphedema: Magnetic Resonance Imaging Evidence of Sparing Centered Along the Cephalic Vein.

J Reconstr Microsurg 2021 Jul 31;37(6):519-523. Epub 2021 Jan 31.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background:  A distinct pattern of edema distribution is seen in breast cancer-related lymphedema. The area of edema sparing has not been characterized in relation to anatomy. Specifically, alternate lymphatic pathways are known to travel adjacent to the cephalic vein. Our study aims to define the location of edema sparing in the arm relative to the cephalic vein.

Methods:  A retrospective review of patients who underwent magnetic resonance imaging (MRI) between March 2017 and September 2018 was performed. Variables including patient demographics, arm volumes, and MRI data were extracted. MRIs were reviewed to define the amount of sparing, or angle of sparing, and the deviation between the center of sparing and the cephalic vein, or angle of deviation.

Results:  A total of 34 consecutive patients were included in the analysis. Five patients demonstrated circumferential edema (no sparing) and 29 patients demonstrated areas of edema sparing. Advanced age (69.7 vs. 57.6 years) and greater excess arm volume (40.4 vs. 20.8%) correlated with having circumferential edema without sparing ( = 0.003). In 29 patients with areas of edema sparing, the upper arm demonstrated the greatest angle of sparing (183.2 degrees) and the narrowest in the forearm (99.9 degrees;  = 0.0032). The mean angle of deviation to the cephalic vein measured 3.2, -0.1, and -5.2 degrees at the upper arm, elbow, and forearm, respectively.

Conclusion:  Our study found that the area of edema sparing, when present, is centered around the cephalic vein. This may be explained by the presence of the Mascagni-Sappey (M-S) pathway as it is located alongside the cephalic vein. Our findings represent a key springboard for additional research to better elucidate any trends between the presence of the M-S pathway, areas of sparing, and severity of lymphedema.
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http://dx.doi.org/10.1055/s-0040-1722648DOI Listing
July 2021

Power-Assisted Liposuction: An Important Tool in the Surgical Management of Lymphedema Patients.

Lymphat Res Biol 2021 02 22;19(1):20-22. Epub 2021 Jan 22.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.

Debulking via power-assisted liposuction has been established internationally as the gold standard for patients with chronic fat-dominant lymphedema. In this study we share our experience implementing a debulking surgery program in the United States. A retrospective review was performed of patients who underwent debulking surgery using power-assisted liposuction at a single institution. Between December 2017 and January 2020, 39 patients with lymphedema underwent 41 extremity debulking procedures. In patients with lymphedema of the upper extremity, median excess volume reduction was 111% at 6 months and 116% at 12 months post-operatively. In patients with lymphedema of the lower extremity, excess volume reduction was 82% at 6 months and 115% at 12 months post-operatively. L-Dex and quality of life improved across all domains in upper and lower extremity patients as well. Debulking with power-assisted liposuction is an effective treatment for chronic lymphedema, supported by improvement in both objective and subjective metrics.
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http://dx.doi.org/10.1089/lrb.2020.0115DOI Listing
February 2021

A Single Institution Multi-Disciplinary Approach to Power-Assisted Liposuction for the Management of Lymphedema.

Ann Surg 2020 Nov 4. Epub 2020 Nov 4.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Objective: To implement and evaluate outcomes from a comprehensive, multi-disciplinary debulking program in the United States.

Summary Background Data: Interest in and access to surgical treatment for chronic lymphedema (LE) in the United States have increased in recent years, yet there remains little attention on liposuction, or debulking, as an effective treatment option. In some other countries, debulking is a common procedure for the surgical treatment of LE, is covered by insurance, and has demonstrated excellent, reproducible outcomes. In this study we describe our experience implementing a debulking technique from Sweden in the United States.

Methods: Patients who presented with chronic lymphedema followed a systematic multi-disciplinary work-up. For debulking with power assisted liposuction, the surgical protocol was modeled after that developed by Håkan Brorson. A retrospective review of consecutive patients who underwent debulking at our institution was conducted.

Results: Between December 2017 and January 2020, 39 patients underwent 41 debulking procedures with power assisted liposuction, including 23 upper and 18 lower extremities. Mean patient age was 58 years and 85% of patients had LE secondary to cancer, the majority of which (64%) was breast cancer. Patients experienced excess volume reductions of 111% and 115% in the upper and lower extremities, respectively, at one year post-operatively. Overall quality of life (LYMQOL) improved by a mean of 33%. Finally, patients reported a decreased incidence of cellulitis and decreased reliance on conservative therapy modalities post-operatively.

Conclusions: Debulking with power assisted liposuction is an effective treatment for patients with chronic extremity lymphedema. The operation addresses patient goals and improves quality of life, and additionally reduces extremity volumes, infection rates and reliance on outpatient therapy. A comprehensive, multi-disciplinary debulking program can be successfully implemented in the United States healthcare system.
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http://dx.doi.org/10.1097/SLA.0000000000004588DOI Listing
November 2020

Surgical cure of clarithromycin resistant breast implant infection: A case report and review of the literature.

J Clin Tuberc Other Mycobact Dis 2020 Dec 5;21:100183. Epub 2020 Sep 5.

Beth Israel Deaconess Medical Center, Division of Infectious Diseases, Department of Medicine, Boston, MA, United States.

Clusters of patients who obtain cosmetic surgeries abroad have developed surgical site infections due to rapid growing non-tuberculous mycobacteria (NTM). These are usually treated with a combination of surgery and months of anti-mycobacterial therapy, but poor outcomes, including permanent scarring are common. We present a case of a 36-year-old female who developed a clarithromycin-resistant (CRMC) infection after undergoing breast augmentation in the Dominican Republic. She underwent debridement and explant of her silicone implants, but due to a series of complications including discordant antimicrobial susceptibility testing profiles, GI side effects, and then pregnancy, she was unable to receive typical multidrug anti-mycobacterial therapy after surgery. She received close clinical follow up and demonstrated full recovery without any evidence of recurrence of infection at 9 months of follow up. We searched the literature for cases of NTM surgical site infection after breast surgery. To our knowledge, this is the first case report of confirmed NTM breast implant infection being cured with surgery alone, and only the second report of clarithromycin resistant in a patient without disseminated infection or pre-exposure to macrolides. The increasing prevalence of drug resistant NTM infections is an emerging concern for clinicians treating patients with complications related to medical tourism.
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http://dx.doi.org/10.1016/j.jctube.2020.100183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490846PMC
December 2020

Lipofilling after breast conserving surgery: a plastic surgery perspective.

Gland Surg 2020 Jun;9(3):617-619

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.21037/gs.2020.04.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7347831PMC
June 2020

Real-Time Visualization of the Mascagni-Sappey Pathway Utilizing ICG Lymphography.

Cancers (Basel) 2020 May 8;12(5). Epub 2020 May 8.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.

Background: Anatomic variations in lymphatic drainage pathways of the upper arm may have an important role in the pathophysiology of lymphedema development. The Mascagni-Sappey (M-S) pathway, initially described in 1787 by Mascagni and then again in 1874 by Sappey, is a lymphatic drainage pathway of the upper arm that normally bypasses the axilla. Utilizing modern lymphatic imaging modalities, there is an opportunity to better visualize this pathway and its potential clinical implications.

Methods: A retrospective review of preoperative indocyanine green (ICG) lymphangiograms of consecutive node-positive breast cancer patients undergoing nodal resection was performed. Lymphography targeted the M-S pathway with an ICG injection over the cephalic vein in the lateral upper arm.

Results: In our experience, the M-S pathway was not visualized in 22% ( = 5) of patients. In the 78% ( = 18) of patients where the pathway was visualized, the most frequent anatomic destination of the channel was the deltopectoral groove in 83% of patients and the axilla in the remaining 17%.

Conclusion: Our study supports that ICG injections over the cephalic vein reliably visualizes the M-S pathway when present. Further study to characterize this pathway may help elucidate its potential role in the prevention or development of upper extremity lymphedema.
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http://dx.doi.org/10.3390/cancers12051195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281680PMC
May 2020

MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements.

Eur Radiol 2020 Aug 27;30(8):4686-4694. Epub 2020 Mar 27.

Department of Radiology, Beth Israel Deaconess Medical Center, Shapiro 463, 330 Brookline Ave., Boston, MA, 02215, USA.

Objectives: Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures.

Methods: Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0-3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen's kappa was calculated to compare MRI staging by two readers.

Results: STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p = 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p = 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (r = 0.63, p < 0.0001), larger % difference in limb volume (r = 0.68, p < 0.0001), and higher L-Dex® ratio (r = 0.84, p < 0.0001). Cohen's kappa was 0.92 (95% CI, 0.85-1.00).

Conclusion: An MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning.

Key Points: • Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists. • MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients. • In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.
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http://dx.doi.org/10.1007/s00330-020-06790-0DOI Listing
August 2020

Is Immediate Lymphatic Reconstruction Cost-effective?

Ann Surg 2019 Dec 10. Epub 2019 Dec 10.

Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Objective: This manuscript is the first to employ rigorous methodological criteria to critically appraise a surgical preventative technique for breast cancer-related lymphedema from a cost-utility standpoint.

Summary Of Background Data: Breast cancer-related lymphedema is a well-documented complication of breast cancer survivors in the US. In this study, we conduct a cost-utility analysis to evaluate the cost-effectiveness of the LYMPHA.

Methods: Lymphedema rates after each of the following surgical options: (1) ALND, (2) ALND + LYMPHA, (3) ALND + RLNR, (4) ALND + RLNR + LYMPHA were extracted from a recently published meta-analysis. Procedural costs were calculated using Medicare reimbursement rates. Average utility scores were obtained for each health state using a visual analog scale, then converted to quality-adjusted life years (QALYs). A decision tree was generated and incremental cost-utility ratios (ICUR) were calculated. Multiple sensitivity analyses were performed to evaluate our findings.

Results: ALND with LYMPHA was more cost-effective with an ICUR of $1587.73/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 1.35 QALY justified an increased incremental cost of $2140. Similarly, the addition of LYMPHA to ALND with RLNR was more cost-effective with an ICUR of $699.84/QALY. In the decision tree rollback analysis, a clinical effectiveness gain of 2.98 QALY justified a higher incremental cost of $2085.00.

Conclusions: Our study supports that the addition of LYMPHA to both ALND or ALND with RLNR is the more cost-effective treatment option.
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http://dx.doi.org/10.1097/SLA.0000000000003746DOI Listing
December 2019

Developing a Lymphatic Surgery Program: A First-Year Review.

Plast Reconstr Surg 2019 12;144(6):975e-985e

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, the Department of Medicine, Division of Cardiovascular Medicine, the Department of Radiology, Division of Magnetic Resonance Imaging, and the Department of Surgery/Breast Care Center, Beth Israel Deaconess Medical Center, Harvard Medical School.

Background: Lymphedema is a chronic condition that carries a significant physical, psychosocial, and economic burden. The authors' program was established in 2017 with the aims of providing immediate lymphatic reconstruction in high-risk patients undergoing lymphadenectomy and performing delayed lymphatic reconstruction in patients with chronic lymphedema. The purpose of this study was to describe the authors' clinical experience in the first year.

Methods: A retrospective review of our clinical database was performed on all individuals presenting to the authors' institution for lymphatic surgery consideration. Patient demographics, clinical characteristics, and surgical management were reviewed.

Results: A total of 142 patients presented for lymphatic surgery evaluation. Patients had a mean age of 54.8 years and an average body mass index of 30.4 kg/m. Patients with lymphedema were more likely to be referred from an outside facility compared to patients seeking immediate lymphatic reconstruction (p < 0.001). For patients with lymphedema, the most common cause was breast cancer related. Thirty-two percent of all patients evaluated underwent a lymphatic procedure. Of these, 32 were immediate lymphatic reconstructions and 13 were delayed lymphatic reconstructions. In the authors' first year, 94 percent of eligible patients presenting for immediate lymphatic reconstruction underwent an intervention versus only 38 percent of eligible lymphedema patients presenting for delayed lymphatic reconstruction (p < 0.001).

Conclusions: First-year review of our lymphatic surgery experience has demonstrated clinical need evidenced by the number of patients and high percentage of outside referrals. As a program develops, lymphatic surgeons should expect to perform more time-sensitive immediate lymphatic reconstructions, as evaluation of chronic lymphedema requires development of a robust team for workup and review.
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http://dx.doi.org/10.1097/PRS.0000000000006223DOI Listing
December 2019

Flow-through Omental Flap for Vascularized Lymph Node Transfer: A Novel Surgical Approach for Delayed Lymphatic Reconstruction.

Plast Reconstr Surg Glob Open 2019 Sep 30;7(9):e2436. Epub 2019 Sep 30.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

The vascularized omental free flap has been described as a reliable option for the treatment of peripheral lymphedema. However, the flap has been associated with venous hypertension which may require venous supercharging or intra-flap arteriovenous fistula creation to offload the arterial inflow. The aim of this study is to introduce and present our experience using a flow-through omental flap as a novel approach to optimize flap hemodynamics. A retrospective review of a prospectively maintained quality improvement database was performed. Seven consecutive patients with unilateral breast cancer-related lymphedema (BCRL) who underwent delayed lymphatic reconstruction using a flow-through omental free flap were identified. In all patients, the right gastroepiploic artery and vein were anastomosed to the proximal end of the radial artery and to one venae comitante, respectively. An anastomosis of the distal end of the radial artery to the left gastroepiploic artery was performed. The flap was then supercharged by anastomosing the left gastroepiploic vein to the cephalic or basilic vein. There were no flap losses or other surgical complications. A distinct advantage of this inset includes the ability to moderate the arterial in-flow to the omental flap to avoid an inflow-outflow mismatch and alleviate venous hypertension. Further study is needed to validate this technique in a larger study sample with longer follow-up.
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http://dx.doi.org/10.1097/GOX.0000000000002436DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6799400PMC
September 2019

A Novel Approach to Quantifying Lymphatic Contractility during Indocyanine Green Lymphangiography.

Plast Reconstr Surg 2019 11;144(5):1197-1201

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Radiation Oncology, Edwin L. Steele Laboratory, Massachusetts General Hospital.

Lymphedema arises from impaired lymphatic function. Quantification of lymphatic contractility has previously been shown using a custom-built near-infrared imaging system. However, to broaden the clinical use of functional lymphatic measurements, these measurements need to be performed using a standard-of-care, clinically available camera. The authors propose an objective, algorithmic, and clinically accessible approach to quantify lymphatic contractility using a 3-minute indocyanine green lymphangiograph recorded with a commercially available near-infrared camera. A retrospective review of the authors' indocyanine green lymphangiography video repository maintained in a Research Electronic Data Capture database was performed. All patients with a newly diagnosed unilateral breast cancer undergoing preoperative indocyanine green lymphangiography were included in the analysis. Patient medical records were then analyzed for patient demographics, and videos were analyzed for contractility. Seventeen consecutive patients with unilateral breast cancers underwent video processing to quantify lymphatic contractility of the ipsilateral extremity in contractions per minute. All patients were women, with an average age of 60.5 years (range, 38 to 84 years). The average lymphatic contractility rate was 1.13 contractions per minute (range, 0.67 to 2.5 contractions per minute). Using a clinically accessible standard-of-care device for indocyanine green lymphangiography, the authors were able to determine lymphatic contractility rates of a normal extremity. The authors' finding falls within the range of previously published data quantifying lymphatic contractility using a research device, suggesting that the authors' technique provides a clinically accessible, time-effective means of assessing lymphatic contractility. Potential future applications include both lymphedema surveillance and evaluation of nonsurgical and surgical interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Diagnostic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000006176DOI Listing
November 2019

Reply: Technological Advances in Lymphatic Surgery: Bringing to Light the Invisible.

Plast Reconstr Surg 2019 11;144(5):942e-943e

Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

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http://dx.doi.org/10.1097/PRS.0000000000006131DOI Listing
November 2019

The All but Forgotten Mascagni-Sappey Pathway: Learning from Immediate Lymphatic Reconstruction.

J Reconstr Microsurg 2020 Jan 9;36(1):28-31. Epub 2019 Aug 9.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Background:  Upper extremity lymphedema occurs in 25 to 40% of patients after axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) or the lymphatic micro- surgical preventative healing approach has demonstrated a significant decrease in postoperative rates of lymphedema (LE) from 4 to 12%. Our objective was to map the Mascagni -Sappey pathway, the lateral upper arm draining lymphatics, in patients undergoing ILR to better characterize the drainage pattern of this lymphosome to the axilla.

Methods:  A retrospective review of our institutional lymphatic database was conducted and consecutive breast cancer patients undergoing ILR were identified from November 2017 through June 2018. Patient demographics, clinical characteristics, and intraoperative records were retrieved and analyzed.

Results:  Twenty-nine consecutive breast cancer patients who underwent ILR after ALND were identified. Patients had a mean age of 54.6years and body mass index (BMI) of 26.6 kg/m2. Fluorescein isothiocyanate (FITC) was injected at the medial upper arm and isosulfan blue was injected at the cephalic vein, or lateral upper arm, prior to ALND. After ALND, an average 2.5 divided lymphatics were identified, and a mean 1.2 lymphatics were bypassed. In all patients, divided FITC lymphatics were identified. However, in only three patients (10%), divided blue lymphatics were identified after ALND.

Conclusion:  In this study, variable drainage of the lateral upper arm to the axillary bed was noted. This study is the first to provide a description of intraoperative findings, demonstrating variable drainage patterns of upper extremity lymphatics to the axilla. Moreover, we noted that the lateral- and medial-upper arm lymphosomes have mutually exclusive pathways draining to the axilla. Further study of lymphatic anatomy variability may elucidate the pathophysiology of lymphedema development and influence approaches to immediate lymphatic reconstruction.
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http://dx.doi.org/10.1055/s-0039-1694757DOI Listing
January 2020

Surgical outcomes of sternal rigid plate fixation from 2005 to 2016 using the American College of Surgeons-National Surgical Quality Improvement Program database.

Arch Plast Surg 2019 Jul 15;46(4):336-343. Epub 2019 Jul 15.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Background: Sternal rigid plate fixation (RPF) has been adopted in recent years in high-risk cases to reduce complications associated with steel wire cerclage, the traditional approach to sternal closure. While sternal RPF has been associated with lower complication rates than wire cerclage, it has its own complication profile that requires evaluation, necessitating a critical examination from a national perspective. This study will report the outcomes and associated risk factors of sternal RPF using a national database.

Methods: Patients undergoing sternal RPF from 2005 to 2016 in the American College of Surgeons-National Surgical Quality Improvement Program were identified. Demographics, perioperative information, and complication rates were reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications.

Results: There were 381 patient cases of RPF identified. The most common complications included bleeding (28.9%), mechanical ventilation >48 hours (16.5%), and reoperation/readmission (15.2%). Top risk factors for complications included dyspnea (odds ratio [OR], 2.672; P<0.001), nonelective procedure (OR, 2.164; P=0.010), congestive heart failure (OR, 2.152; P=0.048), open wound (OR, 1.977; P=0.024), and operating time (OR, 1.005; P<0.001).

Conclusions: Sternal RPF is associated with increased rates of three primary complications: blood loss requiring transfusion, ventilation >48 hours, and reoperation/readmission, each of which affected over 15% of the study population. Smokers remain at an increased risk for surgical site infection and sternal dehiscence despite RPF's purported benefit to minimize these outcomes. Complications of primary versus delayed sternal RPF are roughly equivalent, but individual patients may perform better with one versus the other based on identified risk factors.
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http://dx.doi.org/10.5999/aps.2018.01102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6657184PMC
July 2019

Comment on A Letter to the Editor Regarding "Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (S-LYMPHA) for the Prevention of Breast Cancer-Related Clinical Lymphedema After Axillary Lymph Node Dissection".

Ann Surg 2019 08;270(2):e29-e30

Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Department of Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, New York, NY Department of Surgery/BreastCare Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA Section of Surgical Oncology, Department of Surgery, UF Health, University of Florida School of Medicine, Gainesville, FL Department of Surgery, Unit of Lymphatic Surgery - S. Martino University Hospital, University of Genoa, Genoa, Italy Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000003037DOI Listing
August 2019

Nanowire forest of pnictogen-chalcogenide alloys for thermoelectricity.

Nanoscale 2019 Jul;11(28):13423-13430

Institut Néel, CNRS, 25 avenue des Martyrs, F-38042 Grenoble, France. and Univ. Grenoble Alpes, Grenoble, France.

Pnictogen and chalcogenide compounds have been seen as high-potential materials for efficient thermoelectric conversion over the past few decades. It is also known that with nanostructuration, the physical properties of these pnictogen-chalcogenide compounds can be further enhanced towards a more efficient heat conversion. Here, we report the reduced thermal conductivity of a large ensemble of Bi2Te3 alloy nanowires (70 nm in diameter) with selenium for n-type and antimony for p-type (Bi2Te3-ySey and Bi2-xSbxTe3 respectively). The nanowire growth was carried out through electrodeposition in nanoporous aluminium oxide templates with high aspect ratios leading to a forest (109 per centimetre square) of nearly identical nanowires. The temperature dependence of thermal conductivity for the nanowire ensembles was acquired through a highly sensitive 3ω measurement technique. The change in the thermal conductivity of nanowires is largely affected by the roughness in addition to the size effect due to enhanced boundary scattering. The major factor that influences the thermal conductivity was found to be the ratio of the rms roughness to the correlation length of the nanowire. With a high Seebeck coefficient and electrical conductivity at room temperature, the overall thermoelectric figure of merit ZT allows the consideration of such forests of nanowires as efficient potential building blocks of future TE devices.
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http://dx.doi.org/10.1039/c9nr01566cDOI Listing
July 2019

Lymphedema Incidence After Axillary Lymph Node Dissection: Quantifying the Impact of Radiation and the Lymphatic Microsurgical Preventive Healing Approach.

Ann Plast Surg 2019 04;82(4S Suppl 3):S234-S241

Division of Surgical Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Background: Axillary surgery and radiotherapy are important aspects of breast cancer treatment associated with development of lymphedema. Studies demonstrate that Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) may greatly reduce the incidence of lymphedema in high-risk groups. The objective of this study is to summarize the evidence relating lymphedema incidence to axillary lymph node dissection (ALND), regional lymph node radiation (RLNR) therapy, and LYMPHA.

Methods: We performed a literature search to identify studies involving breast cancer patients undergoing ALND with or without RLNR. Our primary outcome was the development of lymphedema. We analyzed the effect of LYMPHA on lymphedema incidence. We chose the DerSimonian and Laird random-effects meta-analytic model owing to the clinical, methodological, and statistical heterogeneity of studies.

Results: Our search strategy yielded 1476 articles. After screening, 19 studies were included. Data were extracted from 3035 patients, 711 of whom had lymphedema. The lymphedema rate was significantly higher when RLNR was administered with ALND compared with ALND alone (P < 0.001). The pooled cumulative incidence of lymphedema was 14.1% in patients undergoing ALND versus 2.1% in those undergoing LYMPHA and ALND (P = 0.029). The pooled cumulative incidence of lymphedema was 33.4% in those undergoing ALND and RLNR versus 10.3% in those undergoing ALND, RLNR, and LYMPHA (P = 0.004).

Conclusion: Axillary lymph node dissection and RLNR are important interventions to obtain regional control for many patients but were found to constitute an increased risk of development of lymphedema. Our findings support that LYMPHA, a preventive surgical technique, may reduce the risk of breast cancer-related lymphedema in high-risk patients.
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http://dx.doi.org/10.1097/SAP.0000000000001864DOI Listing
April 2019

The Impact of Taxane-based Chemotherapy on the Lymphatic System.

Ann Plast Surg 2019 04;82(4S Suppl 3):S173-S178

Department of Radiation Oncology, Edwin L. Steele Laboratory, Massachusetts General Hospital, Boston, MA.

Background: Breast cancer-related lymphedema affects 700,000 breast cancer survivors in the United States. Although taxane-based chemotherapy regimens are commonly used in the treatment of breast cancer, the impact of taxanes on the lymphatic system remains poorly understood. This study aims to examine the influence of taxane-based chemotherapy on lymphatic function in breast cancer patients.

Methods: A retrospective review of a prospectively-maintained database was performed. Consecutive patients with node positive breast cancer who underwent preoperative indocyanine green (ICG) lymphangiograms were identified. Information including patient demographics, baseline measurements, cancer characteristics, and treatment information were retrieved. Preoperative ICG lymphangiography videos were analyzed and lymphatic contractility was quantified for each subject. Multiple regions of interest were selected on each lymphatic channel and signal intensity was recorded for 3 minutes to generate contractility curves. Each lymphatic contraction was identified using a novel, systematic, and algorithmic approach.

Results: Twenty-nine consecutive patients with unilateral node-positive breast cancer were included for analysis. Average patient age was 54.5 (13) years and mean BMI was 26.8 kg/m (4). The mean lymphatic contractility of patients who received taxane-based neoadjuvant chemotherapy was 0.7 contractions/minute (c/m) (n = 19) compared to 1.1 c/m in those who received no neoadjuvant therapy (n = 10), (P = 0.11). In subgroup analysis, patients who reported taxane induced neuropathy demonstrated significantly lower lymphatic contractility values than those who were asymptomatic or did not receive any chemotherapy (P = 0.018).

Conclusions: In this study, we used a novel method for quantifying and evaluating lymphatic contractility rates in routine ICG lymphangiograms. Diminished lymphatic contractility was noted in patients who received taxane-based neoadjuvant chemotherapy compared with those who did not. Taxane-based neoadjuvant chemotherapy may adversely affect the lymphatic system in the breast cancer population. A larger patient cohort with longer follow-up time is needed to validate this finding and evaluate any potential association with breast cancer-related lymphedema development.
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http://dx.doi.org/10.1097/SAP.0000000000001884DOI Listing
April 2019

A Multimetric Evaluation of Online Spanish Health Resources for Lymphedema.

Ann Plast Surg 2019 03;82(3):255-261

From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA.

Background: Breast cancer is a leading cause of death in US Hispanic females. This demographic is more likely to present with later-stage disease and require more extensive surgical treatment, including axillary lymph node dissection, which increases risk of lymphedema. The Spanish-speaking Hispanic population has a lower health literacy level and requires materials contoured to their unique needs. The aim of this study was to evaluate online Spanish lymphedema resources.

Methods: A web search using the Spanish term "linfedema" was performed, and the top 10 websites were identified. Each was analyzed using validated metrics to assess readability, understandability, actionability, and cultural sensitivity using the SOL (Simplified Measure of Gobbledygook, Spanish), Patient Education and Materials Assessment for Understandability and Actionability (Patient Education and Assessment Tool), and Cultural Sensitivity and Assessment Tool (CSAT), respectively. Online materials were assessed by 2 independent evaluators, and interrater reliability was determined.

Results: Online lymphedema material in Spanish had a mean reading grade level of 9.8 (SOL). Average understandability and actionability scores were low at 52% and 36%, respectively. The mean CSAT was 2.27, below the recommended value of 2.5. Cohen κ for interrater reliability was greater than 0.81 for the Patient Education and Assessment Tool and CSAT, suggesting excellent agreement between raters.

Conclusions: Available online Spanish lymphedema resources are written at an elevated reading level and are inappropriate for a population with lower health literacy levels. As patients continue to use the internet as their primary source for health information, health care entities must improve the quality of provided Spanish resources in order to optimize patient comprehension.
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http://dx.doi.org/10.1097/SAP.0000000000001762DOI Listing
March 2019

Referrals of Plastic Surgery Patients to Integrative Medicine Centers: A Review of Resource Utility.

Ann Plast Surg 2019 07;83(1):3-6

From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Background: Integrative medicine (IM) centers are becoming more established nationwide and provide an expansive range of therapeutic services. Given the high prevalence of IM usage among plastic surgery patients, we sought to define referrals rates to IM centers by plastic surgeons to investigate (1) the role of IM in the continuous care process of plastic surgery patients and (2) whether IM centers are being effectively utilized.

Methods: Institutions with plastic surgery residency programs were identified using the American Medical Association's Fellowship and Residency Electronic Interactive Database Access System in January 2017. Data on the presence of a named IM center, director/administrator contact information, and types of therapeutic services offered were extracted. The total number of IM services at these centers was summed and tabulated for preliminary analyses. A survey questionnaire was sent to the center to ascertain referral patterns in February 2017.

Results: Of 96 institutions with plastic and reconstructive surgery residency programs in North America, 49 (51%) provide IM services, and 24 (25%) have affiliated named IM centers of which we attained a survey response from 13 (54.5%). Of these centers, 10 (76.9%) evaluate more than 50 patients per week. Patient referrals to these centers were primarily from the department of medicine (73.8%) as opposed to surgery (13.1%) (P < 0.0001). An average of 0.77% of surgical referrals, or 0.077% of all referrals, arose from plastic and reconstructive surgery.

Conclusions: Plastic surgeons appear to infrequently refer patients to IM centers. Given the high prevalence of IM usage among our patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field.
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http://dx.doi.org/10.1097/SAP.0000000000001761DOI Listing
July 2019

Technological Advances in Lymphatic Surgery: Bringing to Light the Invisible.

Plast Reconstr Surg 2019 01;143(1):283-293

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; and the Department of Biomedical Engineering, Boston University.

Lymphatic surgery has become an integral and flourishing component of the field of plastic surgery. The diversity of ongoing technological innovations in perioperative imaging, including intraoperative dyes and cameras, allows plastic surgeons to work at the supermicrosurgical level. This study aims to highlight innovations that have shaped and will continue to revolutionize the perioperative management of the lymphatic surgery patient in the future. As additional advances emerge, we need a systematic and objective way to evaluate the efficacy and clinical integration readiness of such technologies. Undoubtedly, these technologies will help lymphatic surgery trend toward increasing objectivity, which will be critical for continued evolution and advancement.
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http://dx.doi.org/10.1097/PRS.0000000000005132DOI Listing
January 2019

Integrative Medicine in Plastic Surgery: A Systematic Review of Our Literature.

Ann Plast Surg 2019 04;82(4):459-468

Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Background: Surveys have reported that as high as 80% of plastic surgery patients utilize integrative medicine approaches including natural products (NPs) and mind-body practices (MBPs). Little is known regarding the evidence of benefit of these integrative therapies specifically in a plastic surgery patient population.

Methods: We conducted a systematic review of studies in MEDLINE, PubMed, and EMBASE (inception through December 2016) evaluating integrative medicine among plastic surgery patients. Search terms included 76 separate NP and MBP interventions as listed in the 2013 American Board of Integrative Health Medicine Curriculum. Two independent reviewers extracted data from each study, including study type, population, intervention, outcomes, conclusions (beneficial, harmful, or neutral), year of publication, and journal type. Level of evidence was assessed according to the American Society of Plastic Surgeons Rating Levels of Evidence and Grading Recommendations.

Results: Of 29 studies analyzed, 13 studies (45%) evaluated NPs and 16 (55%) studied MBPs. Level II reproducible evidence supports use of arnica to decrease postoperative edema after rhinoplasty, onion extract to improve scar pigmentation, hypnosis to alleviate perioperative anxiety, and acupuncture to improve perioperative nausea. Level V evidence reports on the risk of bleeding in gingko and kelp use and the risk of infection in acupuncture use. After year 2000, 92% of NP studies versus 44% of MBP studies were published (P = 0.008).

Conclusions: High-level evidence studies demonstrate promising results for the use of both NPs and MBPs in the care of plastic surgery patients. Further study in this field is warranted.
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http://dx.doi.org/10.1097/SAP.0000000000001676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082151PMC
April 2019
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