The use of the laparoscopically harvested right gastroepiploic lymph node flap may be a safe technique that improves limb measurements and quality of life in extremity lymphedema patients. © 2015 Wiley Periodicals, Inc. Microsurgery 37:197-205, 2017.

The combination of the modified Charles procedure with vascularized transferring of lymph node flap is an effective method for treatment of advanced stage lymphedema.

Vascularized lymph node flap transfer (VLNFT) is a tissue transfer procedure of high interest for the treatment of lymphedema. VLNFT is a new approach for treating lymphedema and during the last few years it is becoming more popular. 1 Different donor sites for VLNFT including groin, supraclavicular, submental, thoracodorsal artery have been described.Herein, we present the results of the successful surgical management of six patients suffering from upper (2) and lower (4) limb lymphedema using a novel vascularized lymph node flap based on the right gastroepiploic (R-GE) vessels. To our knowledge, this is the first report using an intra-abdominal lymph node flap to treat lymphedema.The flap was based on the R-GE artery and vein. Harvest of the flap was performed through an upper midline laparotomy incision. The first step was to identify the right gastroepiploic vessels, then omentum was carefully dissected off the transverse colon with great care not to injure the mesocolon. The left gastroepiploic vessels were then divided and dissection of the short segmental gastric branches allowed the release of the flap from the stomach and permitted complete visualization of the R-GE vessels. Dissection was carried to the level of the right epiploic vessels. The lymph nodes within the flap cannot always be visualized but they often can be palpable. Indocyanine green lymphatic imaging could be performed to confirm the vascularity of the lymph nodes included within the flap.All patients underwent preoperative assessment, including photographs, circumference measurement, lymphoscin-tigraphy, and skin tonicity measurement. Microsurgical anastomoses were performed using the medial plantar vessels end-to-end and the radial artery for end-to-side anastomosis of lower and upper limb lymphedema respectively (Fig. 1). A suction drain was left in situ at the donor-site for 6 days. Patients were discharged on the tenth postoperative day. Post-operative follow-up was performed every 3 months during the first year.After 1 year follow-up all patients exhibited significant improvement and were satisfied with the functional and aesthetic results. Lymphoscintigraphy was performed and improvement was seen in all cases. No postoperative episodes of cellulitis or other complications were observed during the follow-up period.This flap has two mechanisms of function: one is the physiological lymphatic drainage from the interstitium to the vascularized lymph node flap and then into the pedicle vein, 2 and the second is through its ability to absorb the lymphatic fluid by the omentum tissue adjacent to the vascular pedicle. 3 Advantages of the use of this flap include the large diameter of the gastroepipolic vessels, minimal donor-site morbidity, no concern of causing iatrogenic lymphedema, and allowing a two-team approach. This flap contains omentum tissue around the pedicle that will also help in the absorption of lymphatic fluid by the affected limb. The use of laparoscopy to harvest the flap could offer a minimal insult to the abdominal wall ...

Upper limb lymphedema following breast cancer surgery is a challenging problem for the surgeon. Lymphatico-venous or lymphatico-lymphatic anastomoses have been used to restore the continuity of the lymphatic system, offering a degree of improvement. Long-term review indicates that lumen obliteration and occlusion at the anastomosis level commonly occurs with time as a result of elevated venous pressure. Lymph node flap transfer is another microsurgical procedure designed to restore lymphatic system physiology but does not provide a complete volume reduction, particularly in the presence of hypertrophied adipose tissue and fibrosis, common in moderate and advanced lymphedema. Laser-assisted liposuction has been shown to effectively reduce fat and fibrotic tissues. We present preliminary results of our practice using a combination of lymph node flap transfer and laser-assisted liposuction. Between October 2012 and May 2013, ten patients (mean 54.6 ± 9.3 years) with moderate (stage II) upper extremity lymphedema underwent groin or supraclavicular lymph node flap transfer combined with laser-assisted liposuction (high-power diode pulsed laser with 1470-nm wavelength, LASEmaR 1500-EUFOTON, Trieste, Italy). A significant decrease of upper limb circumference measurements at all levels was noted postoperatively. Skin tonicity was improved in all patients. Postoperative lymphoscintigraphy revealed reduced lymph stasis. No patient suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated patients suffering from moderate upper extremity lymphedema.

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Lymph node transfer is a novel technique in lymphedema surgery. In this study, we present our experience in harvesting lymph nodes flap based on the right transverse cervical artery. In a period of 7 months, we harvested 11 cervical lymph node flaps based on the right transverse cervical artery (TCA). The reliable anatomy of the TCA and the low complication rate of the donor site make this lymph node flap ideal for transfer in the treatment of lymphedema. Knowledge of the regional anatomy and the anatomic variations of the TCA are mandatory for safe dissection of this flap. We also present the preliminary results of our first 2 cases in which we performed cervical lymph node transfer for secondary lower extremity lymphedema.

With appropriate patient selection and surgical technique the TUGPAP flap could be a valuable option as an alternative method for autologous breast reconstruction. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

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