Microvascular Transfer of a “Lymphatic-Bearing” Flap in the Treatment of Obstructive Lymphedema

Abstract

Sir: A number of operations have been advocated for the management of obstructive lymphedema. The reestablishment of lymphatic pathways following free tissue transfer has also been documented with lymphoscintigraphic studies in patients who have undergone free flap reconstruction.1–3 We present a new approach to treating obstructive lymphedema using a posterior tibial artery “lymphatic-bearing” free flap, with not only a vascular pedicle but also a lymphatic pedicle to bridge the lymphatic obstruction site. A 23-year-old man presented with lymphedema in his right lower extremity following an extirpative operation for removal of a mass in the right groin 4 years earlier. He was referred to our department with complaints of a recurrent bout of lymphangioitis and increased swelling of his right lower extremity. Preoperative lymphoscintigraphy demonstrated the blockade of lymphatic drainage in the right groin (Fig. 1).Fig. 1.: Preoperative lymphoscintigram shows obstruction of lymphatic drainage in the right groin at 60 minutes after injection.A 7 × 9-cm defect was created after scar excision in the right groin. We then designed an 8 ×10-cm posterior tibial artery “lymphatic” flap in the left lower leg. Before the flap was harvested, 2 ml of patent blue dye was injected into the web space of left foot to visualize the superficial lymphatics of the right leg (Fig. 2). The proximal posterior tibial artery and its accompanying venae comitantes were used as the vascular pedicle of the flap, while one large lymphatic acted as a bridge for direct reconstruction of the lymphatic pathway. The flap was transferred as the standard procedure, but the proximal lymphatic of the flap was anastomosed with a lymphatic collector below the right inguinal ligament, a distal lymphatic of the flap with a lymphatic collector in the middle of medial thigh.Fig. 2.: Intraoperative visualization of the superficial lymphatics by staining with patent blue dye (note the big lymphatic marked by a suture).The flap survived completely, and the patient has not had an episode of lymphangioitis with the obvious lymphedema reduction in the affected leg since the reconstructive procedure. A postoperative follow-up lymphoscintigram at 6 months showed marked improvement of lymphatic drainage by demonstration of the lymphatic pathway along the microsurgically reconstructed lymphatic route (Fig. 3).Fig. 3.: Six-month postoperative lymphoscintigram demonstrating the lymphatic pathway across the reconstructed right groin.The early replacement of resected lymph collectors is the most logical surgical approach to overcome a localized obstruction of lymph flow. Bridging of localized obstruction of lymph drainage by transplantation of lymph collectors was developed by Baumeister et al. in 1981.4 In this patient, we transplanted the lymphatics, which were carried by a free flap with both rich blood and lymph supply, to reconstruct the lymphatic pathway in the obstructive lymphedema. There are two advantages to the lymphatic-bearing flap: first, it can improve the tissue coverage for the lymphatic blockade site; and second, the lymphatic vessels included in a free flap can act as a lymphatic “bridge” to restore the lymphatic outflow by additional microvascular anastomoses with lymphatic vessels in the recipient site. A lymphoscintigram taken at 6 months after operation demonstrated lymph flow across the previous obstruction site along the reconstructed route, which may result from both the reconstructed lymphatic pathway and the flap transplantation. This preliminary report suggests that this operative intervention might be a viable option in the treatment of obstructive lymphedema. Shengli Li, M.D. Weigang Cao, M.D. Kaixiang Cheng, M.D. Ti-Sheng Chang, M.D. Department of Plastic and Reconstructive Surgery Ninth People's Hospital Medical School of Shanghai Jiao Tong University Shanghai, P. R. China