Lymph Node Flap Transfer Research Articles

Preservation of supraclavicular nerve while harvesting supraclavicular lymph node flap.

Lymph node transfer has recently become one of the popular techniques for surgical treatment of lymphedema. We aimed to evaluate postoperative donor site numbness and other complications in patients who underwent supraclavicular lymph node flap transfer to treat lymphedema with preservation of the supraclavicular nerve. From 2004 to 2020, 44 cases of supraclavicular lymph node flap were reviewed retrospectively. In the donor area, sensorial evaluation was clinically done with the postoperative controls. Among them 26 had no numbness at all, 13 had short-term numbness, two had numbness for > 1 year and three had numbness for > 2 years. We suggest that careful preservation of the supraclavicular nerve branches can avoid the major complication of numbness around the clavicle.

Commentary: Lymph-axiality concept awareness reduces trauma-induced lymphedema (commentary on JPRAS-D-20-01255: Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis)

Depending on the stage of secondary lymphedema, surgical treatments can be categorized into reconstructive (e.g., lymphovenous bypass and vascularized lymph nodes transfers 1 Cheng M.H. Chen S.C. Henry S.L. et al. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013; 131: 1286-1298 Google Scholar ) and debulking procedures (e.g., lipoaspiration 2 Brorson H. Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998; 102 (discussion 1068): 1058-1067 Google Scholar , modified Charles’ procedures 3 van der Walt J.C. Perks T.J. Zeeman B.J. et al. Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment. Ann Plast Surg. 2009; 62: 669-675 Google Scholar ). Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosisJournal of Plastic, Reconstructive & Aesthetic SurgeryVol. 74Issue 10PreviewLymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. Full-Text PDF

Lower Limb Lymphedema Patients Can Still Benefit from Supermicrosurgical Lymphaticovenous Anastomosis (LVA) after Vascularized Lymph Node Flap Transfer (VLNT) as Delayed Lymphatic Reconstruction-A Retrospective Cohort Study.

Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.

Evaluation of Free vascularized groin lymph nodes transfer for treatment of secondary upper limb lymphedema

Abstract Background: Vascularized lymph node flap transfer is a recent approach used for the treatment of breast cancer-related upper limb lymphedema. Objective: This work aims to evaluate the effect of vascularized lymph node transfer in the management of secondary upper extremity lymphedema. Methods: a prospective randomized clinical study was conducted including 30 patients stage II-III breast cancer-related lymphedema (BCRL) between December 2017 till June 2020. 15 patients underwent vascularized groin lymph node flap transfer (group B) using the axilla (n = 7) or distal placement (elbow/wrist) (n = 8) as a recipient site. 15 patients who were selected to undergo conservative therapy were used as controls. Intraoperatively, reverse lymphatic mapping using radioisotope or indocyanine green lymphography was performed to avoid iatrogenic lower extremity lymphatic injury. Outcomes were assessed using change of circumferential differentiation, volume reduction rate, and the change in episodes of cellulitis, pain, heaviness, and limb function. Results: At a mean follow-up of 30.07±2.6 months, the mean improvement of circumferential differentiation of group B (VGLNT) was statistically greater than that of group A (conservative physical therapy) (8.3 ± 2.7 percent versus 2.1 ± 4.6; P < 0.01). The evaluation of each treatment showed a significant reduction of infection rate in group B compared with group A (p < 0.001). Conclusion: Vascularized groin lymph node flap transfer using the axilla or distal forearm as a recipient site is an effective and reliable approach for treating breast cancer-related lymphedema.

Supermicrosurgical Lymphaticovenous Anastomosis as Alternative Treatment Option for Moderate-to-Severe Lower Limb Lymphedema

Supermicrosurgical lymphaticovenous anastomosis (LVA) alleviates lymphedema by draining stagnant lymph from the lymphatic vessels into the venous system. Nevertheless, LVA is believed to be unsuitable for treating moderate-to-severe lymphedema presenting diffuse-pattern dermal backflow (DB). Dermal backflow is considered to be the sign of superficial lymphatic functional failure that renders LVA ineffective. Based on a current algorithm, a more invasive vascularized lymph node flap transfer is recommended instead of LVA. This retrospective study aimed to further investigate and possibly challenge this concept. One-hundred patients with unilateral lymphedematous lower limbs who underwent LVA were included. Patients were divided into Group I (10 patients with mild lymphedema) and Group II (90 patients with moderate-to-severe lymphedema). Demographic data and intraoperative findings were recorded. The post-LVA volume reductions by magnetic resonance volumetry were recorded and analyzed. Preoperatively, significant differences were found in BMI (20.6 vs 26.0 kg/m2, p= 0.004) and the volume gained in the lymphedematous limb (396.8 mL vs 1,056.8 mL, p= 0.005) between Groups I and II. Postoperatively, a significant median post-LVA volume reduction (-282.0 mL vs -763.5 mL, p= 0.022) was found in Group II. However, there were no differences in the percentages of post-LVA volume reduction (-43.8% vs -36.4%, p= 0.793) in Groups I and II. The use of supermicrosurgical LVA is as effective at treating moderate-to-severe lymphedema as milder lymphedema. The indication for LVA should be broadened to include such cases.

Efficacy and early results after combining laparoscopic harvest of double gastroepiploic lymph node flap and active physiotherapy for lower extremity lymphedema.

Lymph node flap transfer has gradually gained popularity for the treatment of upper and lower limb lymphedema. The aim of this study is to present the outcomes of an integrated treatment protocol based on double gastroepiploic lymph node flap (DG-VLN) and active physiotherapy in patients affected by Stage II and III lower extremity lymphedema. All Stage II and III lower limb lymphedema patients operated between September 2015 and December 2017 were retrospectively identified and only those treated with an integrated approach of DG-VLN flap and active physiotherapy were included. Outcomes were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Flap viability was evaluated through indocyanine green lymphography. Lymphedema related quality of life was evaluated preop and at 1 year follow up through LYMQOL questionnaire. Sixteen patients met inclusion criteria. Mean follow up was 26.2 months. Significant reduction in lower limb volume was observed for all patients from pre to post intervention. At 3 months of follow up, the mean CRR was 42.4% at below knee (BK) level and 25.4% at above knee (AK) level. At 12 months of follow up, the mean CRR was 58.3% at BK level (p = .001*) and 43.4% at AK level (p < .04*). LYMQOL metrics showed significantly better scores in all domains. Patients with lower limb lymphedema can benefit from combined DG-VLN flap and active physiotherapy, as this approach seem to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Long-term outcome of lower extremity lymphedema treated with vascularized lymph node flap transfer with or without venous complications.

Vascularized submental lymph node (VSLN) transfer is an emerging approach for extremity lymphedema. This study investigated the long-term outcome and venous complications of VSLN for unilateral lower extremity lymphedema. Between 2010 and 2018, patients who underwent VSLN for unilateral lower extremity lymphedema were retrospectively evaluated. Patient demographics, operative records, complications, circumferential improvement, and episodes of cellulitis were analyzed. Further comparisons were performed between different types, numbers, and techniques of venous anastomoses. A total of 75 VSLNs in 70 patients survived, giving a 100% success rate. Six flaps (8%) had venous complications (VC group) and 69 flaps (92%) did not (No-VC group). There were no statistical differences in types, numbers, and techniques of anastomoses between two groups (P = .65, 1, and .56, respectively). At a mean follow-up of 32.0 ± 23.0 months, mean circumferential improvement and episodes of cellulitis between two groups did not statistically differ significantly (P = .31 and .09, respectively). VSLN is an effective treatment for lower extremity lymphedema. The types, numbers of veins, and techniques of venous anastomoses did not statistically affect the venous complication rates. Functional outcomes of the VSLNs were not compromised if venous complications were salvaged promptly.

Postmastectomy upper limb lymphedema: Combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients’ related outcomes. A retrospective comparative study

Lymphedema resulting from breast cancer treatment is a chronic condition that can significantly compromise quality of life. Several works have documented the efficacy of vascularized lymph node flap transfer (VLNT) for the treatment of advanced-stage lymphedema. Given that the axillary scar may contribute to the patient's existing lymphedema, the authors assumed that combining VLNT and scar release with fat graft could be an effective strategy of treatment. The purpose of this study is to compare the efficacy in the reduction of limb circumference and health-related quality of life between a combined strategy, namely, VLN transfer (VLNT) and axillary scar release with fat grafting, and only VLNT for patients affected by postmastectomy upper limb lymphedema. The idea. All patients with stage II and III breast cancer-related lymphedema operated between January 2012 and January 2016 were retrospectively identified, and only those treated by combined VLNT and scar release (Group A) or only VLNT (Group B) were included. The outcomes were assessed clinically by limb circumference measurement and radiologically by lymphoscintigraphy. Lymphedema-related quality of life was evaluated preoperatively and at 1 year follow-up through the LYMQOL questionnaire. Thirty-nine patients met inclusion criteria (Group A = 18; Group B = 21). Mean follow-up was 29 months for Group A and 32 months for Group B. Flap survival rate was 100%, with no donor site morbidity in all patients. A statistically significant difference between the circumference reduction rates (RR) at above elbow level was observed at 3 and 6 months of follow-up comparing the two groups (p<0.00001), with higher values in Group A than in Group B. No significant difference was detected comparing RR values at above and below elbow at 12 and 24 months postoperatively. LYMQOL metrics showed significantly better scores (p<0.0001) in all domains at all follow-up appointments in Group A. Patients with postmastectomy upper limb lymphedema can benefit from combined lymph node transfer and axillary scar release with fat graft, as this approach seems to fasten the onset of improvement and to have a positive impact on patients' quality of life.

Dorsal Wrist Placement for Vascularized Submental Lymph Node Transfer Significantly Improves Breast Cancer-Related Lymphedema.

Background:Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer–related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patients. This study compared the treatment response of breast cancer–related lymphedema with the placement of vascularized submental lymph node flaps at the wrist, between dorsal and volar recipient sites.Methods:A retrospective longitudinal study examined 15 patients receiving vascularized submental lymph node flaps at the wrist performed by a single surgeon with a mean follow-up of 17 months. Clinical and biometric analyses, including quality of life questionnaires, circumference measurements, and number of infections were conducted.Results:All patients showed improvements in quality of life, reduced episodes of cellulitis, and reduced limb circumference measurements compared with preoperative data. Dorsal placement (n = 7) delivered significant reductions in limb circumference at all levels after 1 year (P = 0.04) and in overall function domains in the Lymphedema Specific Quality of Life Questionnaires (P = 0.04) compared with volar placement (n = 8). Venous outflow was greater in the dorsal recipient veins (P < 0.0001).Conclusions:Patients electing to undergo vascularized lymph node transfer to the wrist should be aware that when both options are effective, dorsal placement offers improvement in outcomes despite reduced cosmesis. These results have been incorporated into an evidence-based treatment algorithm that can inform the patient and physician on the decision-making in the breast and plastic surgical spheres.

Outcomes of Lymphedema Microsurgery for Breast Cancer-related Lymphedema With or Without Microvascular Breast Reconstruction.

This study investigated the outcome of lymphedema microsurgery with or without microsurgical breast reconstruction for breast cancer-related lymphedema (BCRL). Complete decongestive therapy, lymphovenous anastomosis, and vascularized lymph node flap transfer are the 3 major treatment modalities for BCRL. Releasing axillary contracture and transferring a free flap may potentially improve the BCRL. Between 2004 and 2015, 124 patients with BCRL who underwent 3 treatment modalities without or with microsurgical breast reconstruction were included in this study as groups I and II, respectively. Patients were offered the lymphedema microsurgery depending on the availability of patent lymphatic ducts on indocyanine green lymphography if they failed to complete decongestive therapy. The circumferential difference, reduction rate, and episodes of cellulitis were used to evaluate the outcome of treatments. Improvements in the circumferential difference (12.8 ± 4.2% vs 11.5 ± 5.3%), the reduction rate (20.4 ± 5.1% vs 14.7 ± 6%), and episodes of cellulitis (1.7 ± 1.1 vs 2.1 ± 2.4 times/yr) did not significantly differ between groups I and II (P = 0.06, 0.07, and 0.06, respectively). In both groups, vascularized lymph node flap transfer was significantly superior to lymphovenous anastomosis or complete decongestive therapy in terms of improvements in the circumferential difference, reduction rate and episodes of cellulitis (P = 0.04, 0.04, and 0.06, respectively). Microsurgical breast reconstruction did not improve the outcome of BCRL. Improvements in BCRL were better for lymphatic microsurgery than complete decongestive therapy. Moreover, vascularized lymph node flap transfer provided greater improvements in the BCRL than lymphovenous anastomosis.

Innovative surgical treatment of peripheral lymphedema after breast cancer surgery

In advanced countries, 98% of upper extremity lymphedema (UEL) are secondary to breast cancer treatments. Nevertheless this disease is quite common, it has been usually neglected and underestimated due to the scarce knowledge about the lymphatic system and the unavailability of effective treatments. As consequence, breast cancer patients are usually not well instructed about the risk of this disease and once UEL is diagnosed they are usually not follow-up by doctors but send for consultation to physical therapist only. The aim of this paper is to provide the status of art of diagnosis and innovative microsurgical treatment of UEL according to the experience of three centers, which provide those treatments as standard-of-care. Different diagnostic procedure can be employed to assess patients affected by lymphedema. Preoperative evaluation of residual lymphatic channel function will guide the therapeutical approach toward conservative, surgical or combined treatment as well as will guide the surgeon on offering lymphaticovenous anastomosis (LVA) versus lymph node flap (LNF) transfer. Microsurgical physiologic procedures are gaining widespread popularity, as they are able to improve lymphedema. LVA should be preferred over LNF transfer when residual lymphatic channels to bypass can be identified preoperatively, because when properly planned and performed, LVA is a less invasive surgery than LNF with higher success rate if good channel can be found. LNF should be reserved to patients with lymphedema refractory to LVA or as first choice when no suitable residual lymphatic channels can be identified preoperatively. Perioperative physical therapy is integral part of the treatment in order to boost the effect of microsurgical treatment.

Innovative surgical treatment of peripheral lymphedema after breast cancer surgery

: In advanced countries, 98% of upper extremity lymphedema (UEL) are secondary to breast cancer treatments. Nevertheless this disease is quite common, it has been usually neglected and underestimated due to the scarce knowledge about the lymphatic system and the unavailability of effective treatments. As consequence, breast cancer patients are usually not well instructed about the risk of this disease and once UEL is diagnosed they are usually not follow-up by doctors but send for consultation to physical therapist only. The aim of this paper is to provide the status of art of diagnosis and innovative microsurgical treatment of UEL according to the experience of three centers, which provide those treatments as standard-of-care. Different diagnostic procedure can be employed to assess patients affected by lymphedema. Preoperative evaluation of residual lymphatic channel function will guide the therapeutical approach toward conservative, surgical or combined treatment as well as will guide the surgeon on offering lymphaticovenous anastomosis (LVA) versus lymph node flap (LNF) transfer. Microsurgical physiologic procedures are gaining widespread popularity, as they are able to improve lymphedema. LVA should be preferred over LNF transfer when residual lymphatic channels to bypass can be identified preoperatively, because when properly planned and performed, LVA is a less invasive surgery than LNF with higher success rate if good channel can be found. LNF should be reserved to patients with lymphedema refractory to LVA or as first choice when no suitable residual lymphatic channels can be identified preoperatively. Perioperative physical therapy is integral part of the treatment in order to boost the effect of microsurgical treatment.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer.

Post-traumatic localized hand lymphedema is a rare situation and its diagnosis may be difficult, causing lack of care leading to failure of care. Our case study is of two young women with massive post-traumatic hand lymphedema who were treated for algodystrophy for 2 years, and whose bandages and physiotherapy were unsuccessful. Major social and psychological consequences due to difficulty with diagnosis and management resulting in inappropriate tests and therapeutic treatment were prescribed due to these issues. Noncontrast magnetic resonance lymphography revealed complete lymphatic vessel blockage in the hand and wrist. A vascularized lymph node flap harvested at the groin level was transferred to the elbow level 1 month after local dermolipectomy. These procedures resulted in the restoration of lymphatic flow. Both patients were definitely cured, and they returned to normal life within 6 months after surgery. Lymph node flap transfer associated with dermolipectomy may cure massive localized lymphedema in selected cases.

Pedicled Transfer of the Superficial Inguinal Lymph Node Flap for Lymphedema

Background Vascularized lymph node transfer is performed for select patients with lymphedema who remain refractory to nonsurgical therapies. Typically, this involves a microvascular free tissue transfer of donor lymph nodes to the affected area. We describe our experience with the transfer of a pedicled adipofascial flap containing the superficial inguinal lymph nodes for lower extremity lymphedema or penoscrotal lymphedema. Methods In eight patients, a unilateral pedicled superficial inguinal lymph node flap was harvested. The flap consisted of subscarpal adipofascial tissue between the level of the inguinal ligament and the groin crease. Blood supply was from either the superficial circumflex iliac vessels or the superficial inferior epigastric vessels. In certain patients, concurrent lymphaticovenular anastomosis was attempted as well. Results Four patients underwent pedicled superficial inguinal lymph node flap transfer for lower extremity lymphedema and for the other four patients the indication was penoscrotal lymphedema. Seven of the eight study patients reported improvements in their lymphedema symptoms. Postoperative complications included cellulitis in one patient and hematoma in another patient; neither patient required reoperation. Conclusion The pedicled superficial inguinal lymph node flap is a feasible and safe treatment option for either lower extremity lymphedema or genital lymphedema. This case series provides the basis for additional studies regarding the potential use of this vascularized lymph node flap in select patients.

Abstract: Lymph Node Flap Transfer and Modified Charles Procedure for Advanced Lower Limb Lymphedema

INTRODUCTION: Lymph node flap transfer (LNFT) is becoming a popular physiologic approach for treating lower limb lymphedema. However, in chronic and severe cases, the Charles’ procedure allows radical reduction of the lymphatic load of the limb and should only be considered when other procedures are not feasible due to its potential complications as infection and poor cosmesis. The aim of this study is to present our experience combining tissue transfer procedures (LNFT) and excisional operations (the modified Charles procedure) for the surgical treatment of advanced lower limb lymphedema. MATERIALS AND METHODS: From July 2010 to May 2015, 45 patients who were diagnosed and treated for advanced lower limb lymphedema with LNFT and a modified Charles procedure were analyzed. In addition, demographics, circumferential limb measurements, lymphoscintigraphy, skin tonicity and postoperative complications were recorded. The reduction rate was describe by the percentage of improvement on skin tonicity and limb circumference. Postoperative follow-up was performed every 3 months during the first year and subsequently every 6 months. RESULTS: After a 4-year follow-up, a total of 45 patients were analyzed. Twelve were male and thirty-three were female. During the follow-up period, all patients exhibited dramatic improvement in lower limb skin tonicity 35.0 % (range 12.5 to 78.0%) (p<0.05). In addition, the average reduction of limb circumference was 60.0% (range 40.0 to 90.0 %) (p<0.05). Moreover, the incidence of cellulitis exhibited a significant reduction in the postoperative period. Only five patients experienced superficial site infection after the operation, which was treated with antibiotics. No major complications were reported postoperatively. However, there were 6 patients with partial skin graft loss requiring re-grafting at the dorsum of the foot. Ten patients required revision and regrafting to improve the cosmesis. Postoperative lymphoscintigraphy displayed improved drainage of the affected limb. In addition, all patients were satisfied with their functional outcomes. CONCLUSION: In cases of severe lower limb lymphedema, the combination of LNFT with the modified Charles procedure can be a good surgical option. This procedure may prevent some potential complications such as recurrence, infection, and aggravation of the disease due to the physiological properties of the transferred lymph nodes. However, further long-term studies are needed in order to rule out recurrence and long-term complications.

Abstract: Laparoscopic Harvest of an Extended Right Gastroepiploic Lymph Node Flap With Double Level Inset in Patients With Extremity Lymphedema

INTRODUCTION: Lymph node flap (LNF) transfer has shown promising results and its becoming one of the mainstay treatment options for extremity lymphedema.1,2,3 However, there are concerns regarding donor site morbidity following LNF harvest.4,5 Also, some observations have been made with regards of the effect of LNF on areas of the extremity away from the transferred flap. Herein, we describe the extended right gastroepiploic lymph node flap (RGE-LNF)3 via laparoscopic approach with a double level flap inset for patients with upper and lower limb lymphedema. MATERIALS AND METHODS: Between 2012 and 2015, patients with grade II and III upper or lower extremity lymphedema were selected for LNF transfer. Preoperative and postoperative limb circumference and lymphoscintigraphy were obtained. All patients underwent laparoscopic harvest of the extended RGE-LNF. In all cases, a double inset was performed at a distal and mid-limb level of the affected limb by dissecting a single flap in two. In addition, etiology of lymphedema, OR time and complications were analyzed. RESULTS: A total of 7 patients were analyzed. The etiology was due to mastectomy and axillary lymph node dissection for breast cancer (n=4) and after hysterectomy and radiotherapy for gynecological cancer (n=3). The survival rate of the flaps after microsurgical transfer was 100%. The average operating time for flap harvest was 37 ± 4.7 minutes; The average time for flap preparation was 8.7 ± 0.8 minutes. The average total operating time including harvest and insets was 245 minutes. The average follow-up period was 14 months. The mean circumference reduction rate of the lymphedematous limb during follow-up was 43.4 ± 4.0% (range, 38.3% to 48.9%). Postoperative lymphoscintigraphy showed improvement of the lymph flow on the affected limb in all cases. No donor-site morbidity was encountered during the follow-up period. CONCLUSION: The laparoscopic harvest of the extended RGE-LNF with a double level flap inset has been showing promising results. Due to the reduction of overall limb volume and symptomatic improvement, this approach may be a new potential treatment option for patients with extremity lymphedema. In addition, minimally invasive approach achieved reduction in donor site morbidity. REFERENCES: 1. Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg. 2014 Jun 19. 2. Ciudad P, Maruccia M, Socas J, Lee MH, Chung KP, Constantinescu T, Kiranantawat K, Nicoli F, Sapountzis S, Yeo MS, Chen HC., The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes. Microsurgery, 2015. 3. Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based onthe right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg. 2013 Oct;73(4):398–401. 4.Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg 2013;45:516–520. 5. Massey MF, Gupta DK. The incidence of donor-site morbidity after transverse cervical artery vascularized lymph node transfers: the need for a lymphatic surgery national registry. Plast Reconstr Surg. 2015 May;135(5):939e-940e.

Abstract: Bi-level Vascularized Lymph Node Transfer: More Effective Than Single Site?

INTRODUCTION: Vascularized lymph node transfer (VLNT) has been established as a viable treatment option for upper extremity lymphedema after mastectomy. This procedure can be completed in conjunction with microsurgical breast reconstruction.1 Various donor sites have been described including the groin2 and the right gastroepiploic lymph nodes.3 The goal of this study was to evaluate and compare outcomes of patients undergoing single level or bi-level VLNT. MATERIALS AND METHODS: A retrospective review was conducted of a single surgeon experience with VLNT from 2014 to 2015 for patients with upper extremity lymphedema following mastectomy. Demographics, medical comorbidities, concurrent procedures, donor and recipient sites, circumferential differentiation (circumference of the lesion limb minus the healthy limb, divided by that of the healthy limb) and circumferential reduction rate (preoperative difference between the circumferences of the lesion and healthy limbs minus the postoperative difference, divided by the preoperative difference) were calculated from measurements obtained at 1 and 3 months post-operatively. Statistical analyses were completed with SPSS 23 (IBM). RESULTS: 14 patients underwent VLNT between 2014 and 2015. 4 patients underwent bi-level VLNT (recipient sites axilla and volar forearm (N =2) and axilla and wrist (N=2). Donor sites were right gastroepiploic lymph nodes (N=3) and deep inferior epigastric lymph nodes (N=1). There were no significant demographic or health differences between the single site and bi-level groups. There were no significant differences in post-op complications related to donor or recipient site, length of stay or revision rate. Circumferential differentiation was not significantly different between the bi-level and single level groups averaged across 3 measurement sites (above the elbow, below the elbow and at the wrist) at 1 month (13.4% vs. 5.7%, respectively, p=0.227), and 3 months (9.6% vs. 1.7%, respectively, p=0.112). Circumferential reduction rate was not significantly different between bi-level or single level groups at 1 month (20.0% vs. 34.3%, respectively, p=0.424) or 3 months (46.6% vs. 37.9%, respectively, p=0.718). CONCLUSIONS: Bi-level VLNT is a viable surgical treatment for upper extremity lymphedema after mastectomy. In this series there were similar complication rates to single site transfer. Bi-level technique and single level technique were not statistically significantly different in terms of circumferential differentiation or reduction rate at short term follow up. Further study is needed to determine if bi-level is superior to single level VLNT long term. 1. Nguyen AT, Chang EI, Suami H, Chang DW. An Algorithmic Approach to Simultaneous Vascularized Lymph Node Transfer with Microvascular Breast Reconstruction. Ann Surg Oncol. 2015:2919–2924. 2. Lin C-H, Ali R, Chen S-C, et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123(4):1265–1275. 3. Ciudad P, Maruccia M, Socas J, et al. The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: technique and outcomes. Microsurgery. 2015. doi: 10.1002/micr.22450

Robotic Harvest of a Right Gastroepiploic Lymph Node Flap.

Lymph node flap (LNF) transfer has proven to be an effective option in the treatment of lymphedema. As a result, much research is presently focused on finding an ideal donor site that results in good clinical outcomes while avoiding iatrogenic lymphedema of the donor area.

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.