Page 34 - Read Online

Page 4 of 8 Jonis et al. Plast Aesthet Res 2023;10:29 https://dx.doi.org/10.20517/2347-9264.2023.06

Preoperatively, NIRF was performed in the outpatient clinic to locate and mark the location for LVA.
During surgery, using the photographs of the markings, the sites for incision are marked. The surgery was
performed under local anesthesia. Incisions of 1.5 to 2 cm were made in the subdermal region to find the
viable lymphatic vessels and subdermal veins. The dissection was performed manually. The anastomosis
was performed either using a robot-assisted approach or manually, depending on the randomization. The
LVAs were performed in an end-to-end fashion with an 11-0 Ethilon suture (Ethicon, Johnson & Johnson,
USA). The patency of the anastomosis was checked by performing the milking test. The wound was closed
[26]
using interrupted transcutaneous sutures with 4-0 Ethilon. The duration of anastomosis was recorded .
The clinical outcomes were health-related quality of life (HRQOL) measured by Lymphedema Functioning,
Disability, and Health Questionnaire (Lymph-ICF), arm circumference measured by the upper extremity
lymphedema (UEL) index, the use of compression garments, patency of the anastomosis and adverse and
severe adverse events were reported .
[27]

Furthermore, technical outcomes such as the amount of anastomosis per procedure, the total time of the
procedure, and the total duration of the anastomosis were recorded. The quality of the microsurgical
technique was compared between the two groups by two independent experienced microsurgeons using the
SAMS and University of Western Ontario Microsurgical Skills Acquisition Instrument (UWOMSA)
assessment methods .
[28]
The Lymph-ICF is a validated questionnaire for patients with lymphedema, consisting of 29 questions based
on function, activity limitations, and participation restrictions divided into five domains. Items are scored
[29]
on a Visual Analog Scale (VAS) from 0 to 100 mm . Higher scores indicate worsening HRQOL. The UEL
index uses circumference measurement of five points on the affected arm and is corrected for body mass
index. A decrease in arm circumference results in a lower UEL index .
[27]

The UWOMSA assesses microsurgical skills in preparation, suturing, and final product. Patient satisfaction
was assessed using a VAS score, and a higher score indicates higher patient satisfaction. The surgeon’s
overall satisfaction with the procedure was assessed, and a higher score indicates higher surgeon
[28]
satisfaction .
There was an improvement in quality of life after LVA surgery for both the manual and the robot-LVA
group after 3, 6, and ultimately 12 months. However, there was no statistically significant difference in
quality of life between the two groups during follow-up (3; 95%CI: -11 to 16, P = 0.679).

The arm circumference measured by the UEL-index showed no statistically significant difference during
follow-up, (Robot-LVA, -0.93 and manual-LVA, 0.36, P = 0.66). Furthermore, a decrease in circumference
measured by UEL-index could not be evidenced for both groups (0.6; 95%CI: -10.3 to 11.4; P = 0.913) .
[26]

After 12 months, a reduction in the use of compression garments was reported in both groups (Robot-LVA
42.9% vs. manual-LVA 45.4% reduction). Additionally, patency was confirmed in 66.6% of patients in the
[26]
robot-LVA group, whereas 81.8% in the manual-LVA group .

None of the patients developed wound infections after surgery. During follow-up, four episodes of
erysipelas occurred in three patients at 6 months postoperatively; these were treated with oral antibiotics .
[26]