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9.10 Clinical Cases
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9.10 Clinical Cases
Case 1
Free lymphatic grafts were used to reconstruct the interruption of the lymphatic pathway in the axillary region
(▶ Fig. 9.4).
Case 2
The transpositioning of lymphatic vessels from a nonaffected leg. Vessel grafts from a healthy lower extremity
may remain attached to the inguinal lymph nodes while
being transposed to the affected groin for the anastomosis
(▶ Fig. 9.5)
Fig. 9.4 A 50-year-old woman after axillary
dissection. (a) Preoperative and (b) 5
months after autologous lymph vessel
transfer.
Fig. 9.5 (a) A 70-year-old patient with
unilateral secondary lymphedema on the
right leg. (b) Twelve years after transpositioning lymphatic vessels from the
nonaffected leg.
Autologous Lymph Vessel Transfer
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References
[1] McHale NG, Roddie IC. The effect of transmural pressure on pumping
activity in isolated bovine lymphatic vessels. J Physiol. 1976; 261(2):
255–269
[2] McHale NG. The lymphatic circulation. Ir J Med Sci. 1992 ; 161(8):
483–486
[3] Frick A, Wiebecke B, Baumeister RGH. Histologische Befunde von
Lymphgefäßen, gewonnen bei Lymphgefäßtransplantationen. In:
Baumeister RGH, ed. Lymphologica Jahresband 1990. München:
Medikon Verlag; 1990
[4] Kinmonth JB. The Lymphatics. London: Edward Arnold; 1982
[5] Wallmichrath J, Baumeister RGH, Herrler T, et al. Experimental study
on the microsurgical or spontaneous formation of lympho-
lymphonodular anastomoses in the rat model. J Plast Reconstr
Aesthet Surg. 2012; 65(4):494–500
[6] Baumeister RGH, Seifert J, Wiebecke B. Transplantation of lymph vessels
on rats as well as a first therapeutic application on the experimental
lymphedema of the dog. Eur Surg Res. 1980; 12 Suppl2:7–8
[7] Springer S, Koller M, Baumeister RGH, Frick A. Changes in quality of life
of patients with lymphedema after lymphatic vessel transplantation.
Lymphology. 2011; 44(2):65–71
[8] Baumeister RG, Seifert J, Wiebecke B, Hahn D. Experimental basis
and first application of clinical lymph vessel transplantation of
secondary lymphedema. World J Surg. 1981; 5(3):401–407
[9] Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical
lymphatic grafting: what is proved? Plast Reconstr Surg. 1990; 85(1):
64–74, discussion 75–76
[10] Weiss M, Baumeister RGH, Frick A, Wallmichrath J, Bartenstein P,
Rominger A. Lymphedema of the upper limb: evaluation of the
functional outcome by dynamic imaging of lymph kinetics after
autologous lymph vessel transplantation. Clin Nucl Med. 2015
Feb;40(2):e117–23
[11] Weiss MF, Baumeister RG, Zacherl MJ, Frick A, Bartenstein P,
Rominger A. [Microsurgical autologous lymph vessel transplantation:
does harvesting lymphatic vessel grafts induce lymphatic transport
disturbances in the donor limb? Handchir Mikrochir Plast Chir
2015;47:359–64.
[12] Wallmichrath, J, Schoepfer D, Frick A. Investigations on the donor
limb after harvest of lymphatic vessels for lymphedema surgery. J
Vasc Surg Venous Lymphat Disord. 2022
132
10 Vascularized Lymph Node Transfer
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Summary
Lymphedema is a pathologic condition that involves the
accumulation of lymphatic fluid leading to tissue swelling. Options for surgical treatment of lymphedema can
be categorized into two groups: excisional and physiological methods. The goal of physiological treatment is to restore the lymphatic drainage. The vascularized lymph
node transfer is a free tissue transfer with lymph nodes
has been practiced in lymphatic surgery for two decades.
It is unclear whether the transferred lymph nodes act as
a sponge to absorb lymphatic fluids into the venous system, or if they really induce lymphangiogenesis. The
groin has been considered as the first choice for many
years. However, other donor sites have been lately described as alternative options, with less risk of potential
iatrogenic lymphedema at the donor site. Indocyanine
green images and reverse lymphatic mapping technology
are mandatory when vascularized lymph node transfer is
planned. This chapter will describe the different available
donor sites, indications, surgical techniques, and outcomes.
Keywords: gastroepiploic lymph node transfer (GELNT),
jejunal mesenteric lymph node transfer (JMLT), lateral
thoracic/thoracodorsal lymph node transfer (LTLNT), lymph
nodes, omental lymph node transfer (OLNT), robotic,
submental lymph node transfer (SMLNT), superficial
inguinal lymph node transfer (SILNT), supraclavicular
lymph node transfer (SCLNT), transplantation, vascularized,
vascularized lymph node transfer (VLNT)
10.1 Donor Sites: Anatomical Basics
and Clinical Reality
Moustapha Hamdi, Chieh-Han Tzou, and Julia Roka-Palkovitz
10.1.1 Inguinal Lymph Node Transfer
The anatomy of the groin area for harvesting superficial
inguinal node transplants (hereafter referred to as
superficial inguinal lymph node t ransfer [SILNT]) is
complex
cial for safe flap harvesting without creating donor site
lymphedema .
pubic tubercle (PT), inguinal ligament, anterior superior
iliac spine (ASIS), femoral arter y and veins, femoral
nerve, and sartorius muscle. The femoral artery lies
lateral to the femoral vein and branches to form the
superficial circumflex iliac artery (SCIA), de ep circumflex iliac arter y (DCIA), superf icial inferior epigastric
8
, and an understanding of this anatomy is cru-
The primary anatomic landmarks in the groin are the
artery (SIEA), and deep inferior epigastric arter y (DIEA)
(▶ Fig. 10.1). The SCIA divides further into a direct
superficial (and more medial) branch and a deeper
(and more lateral) branch, which runs below the deep
fascia, piercing the sartorius, before traveling more
superficially.
Lymph nodes of the groin are located medially/laterally
and deep/superficially to the femoral vessels. Based on
several studies, a mean number of lymph nodes of 6.5
per groin are present.
safely performed, a mean of 3.1 lymph nodes is counted.
In some rare cases, no lymph nodes are found.
Describing the territories of the superficial lymphatic
system and their corresponding lymph nodes is possible
with the concept of “lymphosomes,” presented by Scaglioni and Suami in 2015. The superficial lymph nodes in
the inguinal region are divided into three subgroups
based on the connecting lymphatic vessels: the abdominal group, the lateral thigh group, and the medial thigh
group (▶ Fig. 10.2).
The abdominal lymph node group can be targeted for
SILNT, whereas the medial thigh lymph node group must
be preserved. The lymph nodes responsible for abdominal
lymphatic drainage are located along the lower edge of
the inguinal ligament and supplied by the SCIA or SIEA
and anonymous branches from the common femoral artery. In addition, lymph drainage from the leg via the sentinel lymph nodes and their efferent lymphatic vessels
should be respected.
In a similar concept, Zeltzer et al.
ficial groin into three zones regarding their lymph node
drainage patterns: Zone I is the area medial to the superficial inferior epigastric vein (SIEV), draining the lower
extremity, whereas Zone II drains the lower abdomen,
lower back, and upper gluteal region and is between
the SIEV and the superficial circumflex iliac vein
(SCIV). Within this zone, the most medial and caudal
nodes could also pour the lower extremit y. Zone III is
lateral and caudal to the SCIV and drains the lower
extremi ty.
The authors described a “golden triangle” within Zone
II, where superficial inguinal lymph nodes can be found
and harvested safely (▶ Fig. 10.2).
It was found to be 48 mm from the PT when projected
on a line from the PT to the ASIS, 16 mm caudal to this
line, and 20 mm above the groin crease. It was 41 mm lateral to the SCIV–SIEV confluence (▶ Fig. 10.3).
In summary, the SILNT design should include a functional group of lymph nodes out of Zone II. Lymph nodes
that drain the lower extremity should be excluded.
Lymph nodes medial to the femoral artery drain the
lower extremity. Staying lateral to the artery during flap
2,3,4
In the area where SILNT is
4
divided the super-
Vascularized Lymph Node Transfer
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Fig. 10.1 Anatomy of the inguinal region:
Different lymph node groups adjacent to
the femoral vessels and superficial branch of
the circumflex iliac vessels. Marking of the
inguinal vascularized lymph node flap
(dotted line).
Fig. 10.2 Anatomy of the inguinal region:
The different groups of superficial inguinal
lymph nodes with their corresponding
drainage zones (lymphosomes) of the right
abdominal region and thigh: abdominal in
yellow, lateral thigh in green, and medial
thigh in red (a). The lymph nodes that drain
the medial zone of the thigh (red) and
which are usually found medially to the
femoral vessels have to be preserved.
Anatomic boundaries of the “Golden Triangle” (yellow). The zones marked in blue
often contain lymphatic tissue and therefore should not be included in the LN
flap (a).
harvest is not sufficient in terms of safety. Secondary
lower extremity lymphatic impairment can still occur
after SILNT. A study by Dayan et al.
omy of the flap was completed using magnetic resonance angiography imaging. The study suggested that
there was a cluster of lymph nodes at the confluence of
the SCIA/SCIV and the SIEV, which could be included in
the f lap h arvest. However, a cadaveric study suggests
that lymph nodes at the confluence, along the SIEV and
caudal to the SCI V, c an contribute to lymphatic drainage
of the lower extremity. Including these lymph nodes
with the flap harvest may increase the risk of lower
extremity lymphedema.
134
7
describing the anat-
10.1.2 Supraclavicular Lymph Node
Transfer
The supraclavicular chain of lymph nodes, also known as
the “transverse” chain, is located along the transverse
cervical artery (TCA). It receives afferent vessels from the
anterolateral neck skin, chest wall, mammary gland, and
occasionally from the upper extremity and the infraclavicular lymph nodes. Anterior tributaries connecting the
superficial anterior cervical lymph nodes are located in
the anterior jugular pathway, draining lymph from skin
and muscles of the infrahyoid region, the isthmus of
the thyroid gland, and the infraglottic part of the larynx.
10.1 Donor Sites: Anatomical Basics and Clinical Reality
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Tributaries arise laterally from the accessory lymphatic
chain, and channels from the superficial external jugular
lymph nodes.
The majority of the lymphatic pathways from the
breast toward the supraclavicular apical lymph nodes,
typically terminating in the scalene lymph nodes posterior to the sternocleidomastoid and the clavicle, may drain
Fig. 10.3 Anatomical landmarks to plan the vascularized lymph
node flap of the groin: A line is marked between the pubic
tubercle and the anterior superior iliac spine. In this case, the
lymph nodes to be harvested are located adjacent to a
perforating vessel identified 48 mm lateral to the pubic tubercle
and 16 mm caudal to the marked line.
to the supraclavicular lymph nodes. An “axillary bypass”
directly into these lymph nodes may be present in 5% to
17% of cases.
Efferent lymphatics (typically two to three) form the
supraclavicular trunk, which enters the subclavian venous angle either directly, or via the thoracic duct (or the
right lymphatic duct).
In the left neck, the last lymph node intercalated within
the thoracic duct, after its ascendance in the chest, is
referred to as Virchow’s node. It is located at or near the
jugulo-subclavian venous junction (referred to as the
venous angle).
There is significant anatomic variability of the ar terial
and venous supplies of the supraclavicular region.
The blood supply of the skin component of this flap is
based on the supraclavicular ar tery (SCA) (1.0–1.5 mm)
and vein (1.0–1.5 mm). Cadaver dissections have shown
that the SCA arises 3 to 4 cm from the origin of the TCA,
which is found in the triangle between the dorsal edge of
the sternocleidomastoid muscle (SCM), the external jugular vein (EJV), and the medial part of the clavicle. Moreover, the SCA runs along with two accompanying veins;
one or two veins may drain into the transverse cervical
vein, and the other may drain into the EJV (▶ Fig. 10.4).
When the lymph nodes are harvested without a skin
paddle, blood supply comes from various branches of the
transverse cervical artery and vein as they course through
these lymph nodes (▶ Fig. 10.5). However, one must be
aware that the vascular anatomy in this area can vary
significantly both in terms of the location and size of the
vessels. Major important nerves present in this area are
the phrenic nerve and the vagus nerve (lateral and medial
to internal jugular vein [IJV], respectively).
Fig. 10.4 Anatomy of the supraclavicular
region: Anatomical relationship between
the transverse cervical vessels originating
from the thyro-cervical trunk and the
adjacent lymph nodes. Marking of the
supra-clavicular vascularized lymph node
flap (dotted line).
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Fig. 10.5 Anatomy of the supraclavicular region: Multiple
vascular perforators originate from the transverse cervical artery
and perforate the platysma muscle towards the skin in order to
perfuse the corresponding skin island. The actual lymph node
flap includes the transverse cervical artery, its side branches and
concomitant veins being the flap's pedicle. The lymph nodes of
the supraclavicular regions are in part located adjacent to these
blood vessels. When dissection this flap, the external jugular vein
is usually included into the skin island of the flap to become the
dominant subcutaneous vein for additional venous drainage.
Fig. 10.6 Anatomy of the axillar region: The three axillary lymph
node groups, i.e., lateral, posterior and anterior. Marking of the
axillary vascularized lymph node flap of the lateral thoracic
region (dotted line).
10.1.3 Lateral Thoracic/Thoracodor sal
Lymph Node Transfer
The lateral thoracic lymph node flap involves the transfer
of lymph nodes from the lower part of the a xilla between
the anterior and posterior axillary lines. Anatomical studies of the lymphatic drainage of the axilla have demonstrated discrete organization of the sentinel lymph node
drainage of the thorax and upper extremity, and this
forms the basis of lymph node transfer from this region.
Branches of the lateral thoracic vessels are identified as
well. Lymph node harvest is limited to level 1 (inferior to
lateral border of pectoralis minor) lymph nodes to avoid
damaging the draining lymphatics of the arm. A freestyle
flap is designed, and the lateral thoracic vessels are usually
chosen as their branches tend to preferentially supply the
lymph nodes.
The axilla may be conceptualized as containing five
groups of lymph nodes: lateral, central, posterior, anterior, and apical. Beginning distally along the axillary vein,
the lateral group drains the arm and continues into a central group that receives drainage from the back via posterior group based on the thoracodorsal axis and from the
chest via an anterior group based on the lateral thoracic
axis. The central group then drains into the apical group
of lymph nodes located proximally along the axillary
vein. These lymph nodes drain superiorly into supraclavicular lymph nodes. In practice, these groups are not
clearly defined and there is cross-over drainage between
groups that makes identification of drainage patterns
based on anatomy alone unreliable. It is worth mentioning
that there is a separate drainage pathway, named after
Mascagni, which runs along the cephalic vein in the deltopectoral groove. Some lymphatics from this pathway may
cross over the clavicle and drain directly into deep cervical
lymph nodes, thus bypassing the axillary nodal groups.
The anterior and posterior groups of lymph nodes
are targeted for harvest in axillary VLNT (▶ Fig. 10.6).
The blood supply to these lymph nodes is not consistent
due to variations in the vascular anatomy in the axilla. The
lateral thoracic artery may arise from the thoracodorsal
or subscapular artery in 29% of cases. The lateral thoracic
vein typically arises as a separate branch from the axillary
vein. The artery is 1.3 mm, and the vein is 2.6mm.
The lateral thoracic artery, which is the classic pedicle
to the lateral thoracic lymph nodes, originates from the
axillary artery, but anatomic variations can exist, with
variable origin or complete absence of the lateral thoracic
artery altogether.
An alternative pedicle is the thoracodorsal artery,
which can also supply the lateral thoracic lymph nodes.
However, if the thoracodorsal vessels are utilized for a
lateral thoracic lymph node transfer, this sacrifices the
latissimus dorsi and precludes the use of a workhorse flap
in breast reconstruction.
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An anatomical study revealed on average 13.40 ± 3.13
lymph nodes within the flap. Perforators to the overlying
skin were present in 87.5% of anatomical dissections,
allowing for transfer of a skin paddle.
10.1.4 Submental Lymph Node
Transfer
In the subplatysmal space, key structures can be found
within the various layers of the investing layer of the cervical fascia. The main arterial sources to neck structures
include branches of the external carotid system. The arterial supply to the submental vascularized lymph node
(VLN) flap is based on the submental artery, which is a
consistent branch of the facial artery. The facial artery can
be found approximately 2.0 to 2.5 cm anterior to the
mandibular angle at the level of the lower mandibular
border. Approximately 0.5cm below this point and 6.5 cm
from the origin of this artery, the submental artery can be
found originating as an anterior branch from the facial artery. The average arterial diameter at the origin is approximately 1.5 to 2.0 mm. The key anatomic structures of the
submental region are shown in ▶ Fig. 10.7.
The emergence of the submental artery is in close relation to the submandibular gland. In a majority of cases,
the submental artery can be found between the lower
border of the mandible and the submandibular gland.
Occurring less frequently, the artery runs on the superficial surface of the gland or running between the lobes of
the gland. Following the course past the gland, the artery
travels on the superficial surface of the mylohyoid
muscle, which separates the neck structures from the oral
cavity. During the arterial course, the submental artery
supplies various skin perforators through the platysma
muscle. The distal aspect of the artery can have a variable
course in relation to the anterior belly of the digastric
muscle. In approximately 70% of patients, the distal submental artery travels deep to the digastric muscle, while
the remaining travels superficial to the muscle.
nates in the submental region, where it anastomoses with
the contralateral submental artery. During its course, it
gives rise to several septocutaneous perforating branches,
also supplying the adipose tissue containing submental
(Ia) and submandibular (Ib) lymph nodes.
Venous return is ensured by the submental vein draining into the facial vein, according to a satellite course of
the artery. The facial vein drains inconsistently into the
thyrolinguofacial venous trunk and then into the internal
jugular vein, via a more superficial course than that of the
facial artery, generally above the posterior belly of the
digastric muscle.
Special consideration is warranted for the location of
the marginal mandibular branch of the facial nerve (MMN).
If not, an otherwise successful lymphedema-related surgical result will be overshadowed by the morbidity of injury
to this important structure. Injury to the MMN manifests
as weakness and/or inability to move the ipsilateral lower
lip downward and laterally. Muscles responsible for this action are the depressor anguli oris (DAO) and depressor labii
inferioris (DLI). Injury is apparent on animation of the face
and from asymmetry during smiling.
Harvested vascularized lymph nodes included in the
submental VLN flap are based on the level I lymph nodes
in the Ia and submandibular Ib regions. Ib sublevel is
12
drawing attention as a lymph node hotspot. These lymph
nodes are located in the subplatysmal plane atop the
deep cervical musculature and perfused by the submental artery. The hyoid bone, the mandible, and the anterior
belly of the digastric muscle form the submental triangle.
The anatomic landmarks of the submandibular group of
lymph nodes are posterior to the submental region and
continue from the digastric muscle posteriorly to the posterior aspect of the submandibular gland. Altogether,
both groups comprise the level I lymph nodes and are in
close proximity to the submental/facial artery system
(▶ Fig. 10.7).
13
It termi-
Fig. 10.7 Anatomy of submandibular region: Relationship between lymph nodes,
facial artery and vein, submental pedicle of
the flap, and marginal branch of the facial
nerve and hypoglossal nerve. Marking of the
submandibular vascularized lymph node
flap (dotted line).
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10.1.5 Omental Lymph Node Transfer
The omental flap comprises two dominant pedicles, the
right and left gastroepiploic vessels. The right gastroepiploic artery (RGEA) is preferred because it is larger, has
more epiploic branches, and is easily accessible through a
laparoscopic approach. The omentum consists of a vast
network of lymphoreticular bodies that drain into the
lymphatic collecting system along the right gastroepiploic pedicle and should be preserved during dissection.
10.1.6 Gastroepiploic Lymph Node
Transfer
The gastroepiploic flap is a modification of the free
omental flap, such that the omental tissue is harvested
laparoscopically and is limited to the area adjacent to the
gastroepiploic vascular arcade, since the lymph nodes are
located around these vessels. This allows for the creation
of relatively small lymph node flap (mean: 3 cm × 7 cm)
that allows placement in the distal extremity with minimal impact on cosmetics (▶ Fig. 10.8). The flap is harvested using the right gastroepiploic artery (RGEA) due to
greater accessibility compared with the left side.
The lymph nodes within the RGEA distribution can be
reliably found within 3 cm sur rounding the artery within
the first 9 cm of the RGEA from its origin. Most patients
have at least three lymph nodes within this basin, which
is comparable to other lymph node basins prepared for
VLNT. These findings are consistent and reliable: 75% of
individuals in this study population had identifiable
lymph nodes in the RGEA perf usion area. This lymphosome confers the additional advantage of being located
within the abdomen, in an area without a known risk of
causing iatrogenic lymphedema. Of note, 25% of individuals included in this st udy did not have identifiable
lymph nodes in the RGEA lymphosome. W het h e r these
individuals truly do not have lymph nodes in the RGEA
distribution or whether they were perhaps missed on
imaging remains to be determined. Certainly, this difference supports t he use of CT angiography before harvesti ng RGEA lymph nodes to verify that there are
lymph nodes in the RGEA basin before beginning surgery (▶ Fig. 10.8).
Recent studies have characterized the anatomy of the
vessel and associated lymph nodes with preference for
the RGEA.
for VLNT has become popular due to minimal donor site
morbidity. Although anatomy varies from person to person, CT angiography may help to plan VLNT. The diameter
of RGEA is between 1.5 and 3 mm, and the lymph nodes
are within 3 cm. Although the right gastroduodenal artery (GDA) is typically 4 cm away from the RGEA takeoff,
that distance can be much less, so one must identify it before dissection. With these principles, the plastic surgeon
can safely take the RGEA and surrounding 3 cm of tissue
14
The right gastroepiploic lymph node basin
Fig. 10.8 Anatomy of gastroepiploic region: Omental vascularized
lymph node flap based on the gastroepiploic vessels. Marking of
the omental vascularized lymph node flap (dotted lines) including
several lymph nodes adjacent to the gastroepiploic vessels along
the greater curvature of the stomach.
to include three lymph nodes when planning for a right
gastroepiploic VLNT.
10.1.7 Jejunal Mesenteric Lymph Node
Transfer
The jejunum is the middle segment of the small intestine
and functions primarily in the digestion and absorption
of enteric contents. It comprises approximately two-fifths
of the total length of the small intestine and itself measures roughly 2.5 m in length. The mesentery, which is a
double fold of the peritoneum, suspends the small and
large intestines from the posterior abdominal wall and
houses their vascular, lymphatic, and nervous supply.
The jejunum receives its blood supply from the superior mesenteric artery (SMA), which originates from the
aorta anterior to L1 and approximately 1cm inferior to
the takeoff of the celiac artery. From there, the SMA proceeds inferiorly, passing behind the neck of the pancreas
and the splenic vein, before giving rise to several jejunal
arteries, which run in parallel to each other within the
layers of the mesentery. As these vessels travel toward
the small intestine, the jejunal arteries further divide into
branches that have numerous anastomoses with adjacent
branches to form a series of arterial arcades. The collateral
flow conferred by these anastomoses serves as the basis
for the ability to selectively divide mesenteric branches
without causing ischemia. The venous drainage of the
small intestine occurs through the superior mesenteric
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10.2 Indications and Contraindications
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vein, which ultimately joins the splenic vein to empty
into the portal system.
Cadaveric investigation has found that the greatest number of lymph nodes exist within the proximal third of the
jejunum, where there is an average of 19.2 total lymph nodes, a significantly greater number than in the middle and
distal thirds. The lymph nodes can be divided into those
located in the periphery of the mesentery closer to the
bowel and the more plentiful lymph nodes located centrally
and closer to the larger vessels at the root of the mesentery.
The lymph nodes present in the periphery are usually supplied by vessels that measure approximately 1.5 to 3 mm in
diameter (with the vein measuring approximately 0.5 mm
larger than the associated artery) and have a more robust
capillary network around the lymph nodes, making them
an ideal target for a standard end-to-end or end-to-side
anastomosis at the recipient site. The arterial inflow and
venous outflow should be well balanced in these flaps as
they represent more of an “end organ” to the pedicle, not
unlike other fasciocutaneous flaps that we routinely use,
such as the anterolateral thigh flap. However, these peripherally located lymph node flaps may include the anastomotic loops and straight arteries to the jejunum and thus
may potentially devascularize a segment of the bowel and
should be carefully chosen by transillumination. Use of
these relatively smaller vessels for microsurgical transfer,
compared to those in proximity to the root of the mesentery, achieves a better size match with the flap itself, which
typically measures approximately 3 cm.
The lymph nodes located toward the root of the mesentery can be harvested with less concern about related
bowel ischemia due to the tremendous arborization and
redundant vascular connections through anastomotic
loops toward the periphery of the mesentery. However,
the larger vessels at the mesenteric root (the artery and
vein typically measure approximately 3 mm and 4-6 mm,
respectively) carry a tremendous amount of blood to and
from the jejunum, which largely bypasses the small capillary perforators to the lymph nodes in this area. Therefore, a standard end-to-end vascular connection of the flap
pedicle to donor vessels at the recipient site may result in
a significant vascular inflow and outflow imbalance and
even flap loss, unless a more physiologic connection, such
as a flow-through design of the flap artery and vein or an
arteriovenous loop at the distal end of the flap pedicle, is
included.
18
10.2 Indications and
Contraindications
Holger Engel
Indications for autologous lymph node transfer have developed dramatically in the last 10 years and knowledge
of lymphatic surgery has increased. Initially, lymph node
transfer was indicated for certain lymphedema staging/
classification levels (e.g., International Society of Lymphology [ISL] stage II/III) or after a fixed period of conservative treatment, not infrequently for up to 2 years,
without any improvement or worsening conditions. Currently, the indication and the time point of intervention
for autologous lymph node transfer are determined based
on a specific patient-centered assessment and in an embedded multimodal therapy setting. This approach is supported by recently published data demonstrating that
patient-reported outcomes might be more critical in predicting long-term health-related quality of life than
clinician-measured results.
A sequential approach in a multimodal setting is
described in detail in the algorithm in Chapter 18.In
brief, lymph node transfer is indicated when options for
conservative treatment and lymphovenous anastomosis
(LVA) have already been used and reached their limits.
This is the case when, for example, total occlusion of
lymphatics or partial occlusion on lymphoscintigraphy
combined with increasing episodes of cellulitis is present.
This could already be the case in lymphedema severity
stage I on the ISL scale and in “stardust” or “diffuse” formation described by Yamamoto et al.
tween one stage versus sequential use of combined surgical
procedures is discussed in Subchapter 15.5. Patients with
ISL stage III or IV should undergo adjunctive lipectomy or
debulking procedures before lymph node transfer.
Contraindications are dependent on patients’ health
status and expected donor site morbidities. In general,
the patient should be healthy enough to survive the operation and should also be able to follow a dedicated
aftercare schedule postoperatively. One should act with
extreme caution with patients suffering from tumor, e.g.,
local recurrences and distant metastasis. Additionally, undetected metastasis, or a local tumor disease, within the
lymph node transplant could be brought to the recipient
site, making oncologic therapy difficult or impossible.
Depending on the tumor type, prognosis, and expected
treatment, in select cases there could be an indication if
there is a high probability of increasing quality of life by
decreasing lymphedema suffering.
Patients suffering from brachial plexus neuritis or
chronic regional pain syndrome are also contraindicated.
Relative and absolute contraindications are present in
the event of pre-existing disease, trauma, operation, or
radiotherapy of the donor site. For example, a patient
with multiple operations of the intestine is not an ideal
candidate for jejunal mesenteric lymph node transfer due
to the extensive scarring and increased donor site morbidity. Patients with lymphedema of the lower extremity
develop rerouting lymphatic ducts to the other side of
the groin area. Therefore, it is obsolete to harvest groin
lymph nodes from that area. The same principle applies
to patients suffering from head and neck lymphedema
after modified unilateral neck dissection. Submental
lymph nodes are obsolete in this condition.
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The controversy be-
Vascularized Lymph Node Transfer
https://t.me/medicina_free
10.3 Preoperative Evaluation and
Planning
Holger Engel
Preo perative evaluation and planning are crucia l for
selecting the right patients for VLNT and achieving the
best outcomes. The preoperative assessment contains a
thorough clinical examination, ICG lymphangiography,
ultrasound, an d MRI. Patient selection is also based
on the severity of the disease and patient-specific characteristics.
The clinical examination can be used to determine the
patient’s ISL stage, identify previous surgeries and scars,
and inspect available donor/recipient sites. Any skin
changes, cellulitis, or open wounds associated with advanced lymphedema stages will affect the selection of VLNT
recipient sites due to the risk of postoperative infections.
Sometimes, lymphoablative surgery must be performed
before or concurrently with reconstructive VLNT. Patients
with severe lymphedema visible as “pitting edema” should
undergo conservative treatment first with complete decongestive therapy to optimizethe condition before VLNT.
Severe obesity should be treated first because of its
negative influence on the whole healing process and
has to be diffe rent iated from fat depositions of the
extremities caused by chronic inflammation of lymphedema. With massive fat deposits, lipectomy should also
be considered.
ICG lymphangiography is one of the essential tools for
evaluating lymphatic function, accurate diagnosis, and
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staging.
called the “diffuse pattern” after Yamamoto, no functioning lymph collectors are visible, and lymph node transfer
is recommended. Because ISL staging is not a reliable tool
for treatment planning and tracking outcomes, Cheng’s
grading can be an alternative. Direct VLNT is recommended for Cheng’s grade II or above.
Preoperative ultrasound and MRI can help to evaluate
the donor and recipient sites. The goal is to clarify anatomical details and to include as many lymph nodes as
possible within the lymph node flap. The recipient vessels
should be patent with adequate flow and size.
CT angiography is not mandatory unless a history of
trauma or peripheral vascular disease is present. Duplex
Doppler helps to clarify the patency of the venous system
regarding superficial or deep venous incompetence.
In patients with advanced dermal backflow
17
10.4 Choice and Management of
Donor and Recipient Sites
Holger Engel and Katrin Seidenstücker
The choice of the donor and recipient sites depends on
various factors. The surgeon’s preference may differ regarding the experience level, anatomical knowledge, and
armamentarium that is available. Patient factors include
previous surgeries, scars, and cosmetic concerns. There
are anatomical differences regarding the quantity and
density of donor lymph nodes, reliable and sizable
pedicles, and iatrogenic lymphedema risks.
Initially, the groin area was a popular area for harvesting superficial inguinal lymph node transplants.
Unfortunately, without thoroughly performed intraoperative reversed mapping, there is a risk of iatrogenic lymphedema. This is also true for thoracodorsal lymph node
transplants, where axillary reverse mapping (ARM) is
mandatory. Therefore, preferences have shifted from the
groin area and thoracodorsal lymph nodes to submental,
supraclavicular, and abdominal donor sites for VLNT.
They are utilized only when there is a contraindication
for the other VLNT, due to patients’ preference, for cosmetic reasons, or due to an inadequate number or size of
lymph nodes.
Submental, supraclavicular, and jejunal mesenteric donor sites could demonstrate a high quantity and density
of lymph nodes with minimal risks of iatrogenic lymphedema as well as reliable pedicles.
ploic and omental donor sites have revealed a lower
number of lymph nodes per t ransplant. A drawback of
jejunal mesenteric lymph node transplants is often the
short and small pedicle, making the dissection and anastomosis tedious.
An advantage of submental and jejunal mesenteric
VLNT is that multiple flaps (submental two/jejunal mesenteric up to three) can be harvested from one donor site
at the same time.
ferent recipient sites in a one-stage operation.
The recipient site’s choice depends on previous surgery
scars, cosmetic concerns of the patient, availability of the
recipient’s vessels, and different severity of lymphedema
at various levels of the extremity. Whether the surgeon
believes in the “pump-gravity theory” or not is also
essential.
22
These flaps can be transplanted to dif-
21
In contrast, gastroepi-
5,21
10.4.1 Proximal versus Distal Recipient
Area, Scar Management, and Flap Types
In general, recipient sites are divided into proximal
anatomic areas such as the axilla and groin and distal
“nonanatomic” sites such as the elbow, wrist, knee, and
ankle.
There is st ill controversy regarding whether proximal
or distal recipient sites are superior. Surgeons and authors who prefer the proximal recipient area emphasize the advantages of extensive scar removal along
with the replacement of well-vascularized t issue in the
site. Another advantage is that the scars are easily hidden and therefore provides acceptable to good cosmetic
results. On the other hand, with extensive scarr ing, r ecipient vessel dissection is technically more challenging. If the dissection proceeds deep into the a xilla, a
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