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Optimization of Vascularized Lymph Node Transfer Outcomes Utilizing Pre- and Post-Operative Physical Therapy Protocols
Jonathan R. Sarik, MD, Richard DeMaria, LPT, Patrick J. Greaney, MD.
Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Background: Lymphedema, the accumulation of excess interstitial fluid in tissues, is a complex disease process that occurs when fluid overwhelms the lymphatic system’s absorptive capacity. Unilateral upper extremity lymphedema following treatment for breast cancer occurs in approximately 21% of patients, and is likely underreported. Advanced treatments for peripheral lymphedema such as vascularized lymph node (VLN) transfer show promising results for the treatment of lymphedema; however the complex nature of the disease process requires a multidisciplinary approach for optimal recovery. The combination of preoperative lymphedema management with physical therapy, manual lymphatic drainage and compression devices followed by VLN transfer and postoperative physical therapy may hold promise for patients and surgeons in achieving long-term lymphedema management. The role of an organized pre- and post-operative physical therapy regiment with VLN transfer is not well delineated in the literature. Herein we describe our practice’s use of a structured physical therapy regimen in conjunction with VLN transfer to provide optimal outcomes.
Methods: The group’s approach to the initial preoperative treatment of lymphedema focuses on patient education and a progressive physical therapy regimen. Patients have twice weekly physical therapy sessions that include routine limb volume assessments and manual lymphatic drainage. Patients are initially given an independent home therapy regimen that includes elevation of the affected limb, no-weight and low-weight extremity pumping exercises twice per day, and instructions for meticulous skin care. The home exercise regimen is then expanded to include twice daily pneumatic pump therapy for 30 to 45 minutes each session. Each pneumatic pumping session is followed immediately by the application of a gradient compression for 6 hours.
Following VLN transfer surgery, the postoperative physical therapy regimen also includes both home care and twice weekly physical therapy assessment and treatment. Home therapy includes limb elevation, no-weight and low-weight pumping exercises five times daily and gentle compression wrapping. This includes gentle static compression on recipient site. For upper extremity lymphedema this includes both the elbow to the hand distally (for wrist based VLN flaps), and the elbow to the axilla proximally to distribute the lymph fluid to the VLN graft as well as centrally to the patient's native axillary lymphatic bed. These compression wraps are not to exceed 40 mmHg and are cycled for six hours of compression with three hours of no compression. Twice weekly physical therapy sessions continue to include routine volume assessments as well as manual lymphatic drainage. The manual lymphatic drainage technique is similarly performed in both a proximal-to-distal (elbow to wrist) and distal-to-proximal (elbow to axilla) fashion and also includes distal-to-proximal manipulation from the digits to wrist.
Conclusion: The complex nature of peripheral lymphedema requires a multidisciplinary approach to achieve durable successful management. The use of progressive, multimodal preoperative therapy followed by VLN transfer, and a strict postoperative therapy program is described herein. The authors believe that this approach to the management of peripheral lymphedema provides optimal
treatment and allows for continuing evaluation of disease resolution. Future studies should be directed at assessing the efficacy of this and other treatment regimens.

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