Does Delayed Reconstruction Affect Lymphedema? Another Viewpoint
Joshua Fosnot, MD, Shareef Jandali, MD, John P. Fischer, MD, Liza C. Wu, MD, Joseph M. Serletti, MD.
The University of Pennsylvania Health System, Philadelphia, PA, USA.
BACKGROUND: Lymphedema is a well documented complication of treatment for breast cancer. A recent retrospective report concluded new onset lymphedema was rare following delayed reconstruction and may decrease its severity in preexisting disease. The purpose of this study was to assess the patient’s perspective.
METHODS: The design of this study was a retrospective review of delayed unilateral breast reconstruction performed by the senior authors between 2005 and 2009 combined with the use of a well validated survey instrument which can be used to diagnose lymphedema. Patients were mailed a series of questions to determine if they had lymphedema. In addition, they were asked separate questions about reconstruction’s effect on arm symptoms.
RESULTS: During this time period, 90 patients underwent delayed unilateral breast reconstruction with an autologous free flap. After two mailings, 66.6% (n=60) of patients returned the survey and were included in data analysis. Of the 60 respondents, 10.0% (n=6) had been diagnosed and documented as having lymphedema in the medical record. In evaluating the recent report on lymphedema, the prevalence of lymphedema in their patient population was 7.9%. These are in stark contrast to the survey which reported 48.3% (n=29) with lymphedema (p=0.01) which is more consistent with previous reports of lymphedema following mastectomy. Overall, 28.3% (n=17) reported mild lymphedema and 20.0% (n=12) reported moderate/severe lymphedema. Of those diagnosed by survey, 51.7% thought there was no change, 27.6% were worse, 20.7% were better following reconstruction. Although not necessarily indicative of a diagnosis of lymphedema, when asked questions about arm symptoms 38.4% thought their symptoms were worse, 30.8% reported no change and 30.8% stated they were better. Of those patients with lymphedema by survey, only 18.5% reported discussing this with their plastic surgeon.
CONCLUSIONS: Overall, the prevalence of lymphedema was similar to published reports in the cancer literature, but much more common than reported in our plastic surgery clinic or recent plastic surgery literature. On the whole, delayed reconstruction appears to have no effect on lymphedema. Although more prospective study is necessary to answer this question conclusively, as part of a multidisciplinary team, plastic surgeons should be aware that lymphedema is common, patients may not volunteer their symptoms and may in fact benefit from specific questioning to aid in diagnosis and treatment.
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