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18.4 Conclusions
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Fig. 18.2 Treatment algorithm for diagnostic workup and modern surgical management of lymphedema for lower and upper extremity lymphedema, breast cancer-related lymphedema, and
lymphedema characterized by fibrosis of fat hypertrophy.
Treatment Algorithm for the Surgical Management of Lymphedema
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References
[1] Mihara M, Hara H, Araki J, et al. Indocyanine green (ICG) lymphography
is superior to lymphoscintigraphy for diagnostic imaging of early
lymphedema of the upper limbs. PLoS One. 2012; 7(6):e38182
[2] Yamamoto T, Yamamoto N, Doi K, et al. Indocyanine green-enhanced
lymphography for upper extremity lymphedema: a novel severity
staging system using dermal backflow patterns. Plast Reconstr Surg.
2011; 128(4):941–947
[3] Bae JS, Yoo RE, Choi SH, et al. Evaluation of lymphedema in upper
extremities by MR lymphangiography: comparison with
lymphoscintigraphy. Magn Reson Imaging. 2018; 49:63–70
[4] Hayashi A, Visconti G, Yamamoto T, et al. Intraoperative imaging of
lymphatic vessel using ultra high-frequency ultrasound. J Plast
Reconstr Aesthet Surg. 2018; 71(5):778–780
[5] Hayashi A, YamamotoT, Yoshimatsu H, et al. Ultrasound visualization
of the lymphatic vessels in the lower leg. Microsurgery. 2016; 36(5):
397–401
[6] Bianchi A, Salgarello M, Hayashi A, Yang JC, Visconti G. Recipient venule
selection and anastomosis configuration for lymphaticovenular
anastomosis in extremity lymphedema: algorithm based on 1,000
lymphaticovenular anastomosis. J Reconstr Microsurg.2021
[7] Yang JC, Wu SC, Chiang MH, Lin WC, Hsieh CH. Intraoperative
identification and definition of “functional” lymphatic collecting vessels
for supermicrosurgical lymphatico-venous anastomosis in treating
lymphedema patients. J Surg Oncol. 2018; 117(5):994–1000
[8] Yang JC, Wu SC, Lin WC, Chiang MH, Chiang PL, Hsieh CH.
Supermicrosurgical lymphaticovenous anastomosis as alternative
treatment option for moderate-to-severe lower limb lymphedema. J
Am Coll Surg. 2020; 230(2):216–227
[9] Basta MN, Gao LL, Wu LC. Operative treatment of peripheral
lymphedema: a systematic meta-analysis of the efficacy and safety of
lymphovenous microsurgery and tissue transplantation. Plast
Reconstr Surg. 2014; 133(4):905–913
[10] Hirche C, Engel H, Seidenstuecker K, et al. [Lympho-reconstructive
microsurgery for secondary lymphedema: consensus of the GermanSpeaking Society for Microsurgery of Peripheral Nerves and Vessels
(DAM) on indication, diagnostic and therapy by lymphovenous
anastomosis (LVA) and vascularized lymph node transfer (VLNT)].
Handchir Mikrochir Plast Chir. 2019; 51(6):424–433
[11] Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM.
Donor-site lymphatic function after microvascular lymph node
transfer. Plast Reconstr Surg. 2012; 130(6):1246–1253
[12] Saaristo AM, Niemi TS, Viitanen TP, Tervala TV, Hartiala P,
Suominen E A . Microvascular breast reconstruction and lymph
node transfer for postmastectomy lymphedema patients. Ann
Surg. 2012; 255(3):468 – 473
[13] Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy
lymphedema: long-term results following microsurgical lymph node
transplantation. Ann Surg. 2006; 243(3):313–315
212
19 Review of the Current Literature
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Mario F. Scaglioni and Matteo Meroni
Summary
This chapter will highlight the current scientific evidence
available that describes the different surgical procedures
to be used to treat lymphedema. Since comparative studies are still infrequent, most studies available nowadays
are more or less big case series and expert opinion based
on personal experience and, therefore, the level of evidence is rather low. Yet, over the last years, the surgical
management of lymphedema has undergone a true revival,
particularly with regard to reconstructive microsurgery
and therefore resulted in a continuous increase in scientific
evidence. This chapter summarizes the current state of
pre-, intra-, and postoperative visualization and monitoring
of the lymphatic vascular system. Further, it highlights the
currently used surgical procedures, both when offering
lymphoablative surgery and reconstructive surgery, as a
standalone procedure or in combination. It also highlights
reconstructive surgery in a prophylactic setting, i.e., while
performing lymph node dissection during oncological
surgery, and finally describes potential therapeutical
approaches based on scientific consensus.
Keywords: diagnostics in lymphedema, lymphoablative
surgery, lymphovenous anastomosis (LVA), lymph node
vein anastomosis (LNVA ), nonvascularized lymph vessel
transfer, reconstructive surgery, suction-assisted lipectomy,
vascularized lymph node transfer (VLNT)
19.1 Introduction
Lymphedema is characterized by an accumulation of fluid
and protein in the interstitial space of subcutaneous tissues caused by obstruction or impairment of lymphatic
fluid transport. This may result in swelling of the affected
limb with discomfort, sometimes pain, impaired range of
motion, and recurrent infections. If this potentially progressive and debilitating condition becomes chronic,
irreversible changes, such as tissue fibrosis and excess of
adipose tissue, will inevitably occur
and 2). Its first-line treatment is dictated by conservative
measure of complete decongestive therapy (CDT) that is
crucial as a stand-alone treatment as well as before and
after a surgical procedure (see Chapter 6 and Subchapter
7.3. Unfortunately, many cases are resistant to conservative measures, i.e., CDT maintains the stage of lymphedema rather than truly improving it.
Accordingly, a variety of surgical measures have been
described that aim at reducing, almost always, the excess
subcutaneous tissue and sometimes skin or at least somehow restoring the circulation of lymphatic fluid. They
include suction-assisted lipectomy (see Chapter 13) and
1,2
(see Chapters 1
surgical techniques aiming at excising excess of skin and/
or subcutaneous fat (see Chapter 14). Yet, both approaches treat the symptoms rather than really the cause.
This is why lately more sophisticated microsurgical and
potentially causal approaches have become more and
more popular. These so-called physiological procedures
aim at reducing the lymphatic fluid burden by improving
lymphatic circulation by diverting (see Chapter 8) and
bypassing (see Chapter 9) lymphatic blockage and/or
creating alternate outflow pathways by developing new
lymphatic drainage pathways (see Chapter 10).
The increasing popularity of this surgery is not only
reflected in a continuous increase of colleagues who perform congresses and courses that promulgate this type of
surgery, but also the increase in number and level of evidence (LoE) in the literature.
This chapter shall highlight the current status of the
literature with regard to new diagnostic tools that have
been implemented in microsurgical reconstructive procedures to treat lymphedema. Further, it will highlight the
actual status of the two most popular surgical procedures
used to treat lymphedema, i.e., lymphvenous anastomosis
(LVA) and vascularized lymph node transfer (VLNT).
19.2 Lymphoreductive Surgery
Surgical procedures that aim at reducing the tissue excess
were mainly used historically. However, they may be used
in advanced stages of lymphedema or in remote areas of
the world where they lack microsurgical equipment or as
a concomitant or staged adjunct to reconstructive microsurgery of the lymphatic system (see Chapters 8–12).
The forerunner of this type of surgery was the Charles’
procedure first described in 1912. The procedure involved
circumferential excision of skin, subcutaneous tissue,
muscle fascia, followed by grafting of the excised skin to
finally cover the iatrogenic defect resulting from the excision. Later on, modifications have been described by Sistrunk in 1927 and Homan-Miller in 1936 to decrease the
invasiveness of the method. Approximately 30 years later,
Thompson further modified the technique in order to
induce spontaneous lympho-lymphatic and lymphovenular connections by transposing thin and deepithelialized superficial flaps of the surrounding skin excess into
the deeper muscular tissue eventually linking superficial
adipo-dermal lymphatic drainage system to the deep
muscular system.
Unfortunately, all these procedures are associated with
a rather high rate of complications, including pain, wound
healing complication, infections, hypertrophic and retractile scars, and lymphatic fistulas.
surgery is used only occasionally in developed countries
2
Therefore, this type of
Review of the Current Literature
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in cases of severely voluminous extremities, whereas it
might be used on regular basis in filariasis-associated
severe forms of lymphedema (see Chapters 3 and 12).
Another far less invasive surgical approach that reduces
the volume of tissue excess is lipectomy. The feasibility is
based on the fact that subcutaneous tissues exposed to
chronic lymphedema progressively converts first into excessive fatty tissue and eventually fibrotic tissue. Accordingly, Brorson took advantage of that pathophysiological
change of tissues in order to remove subcutaneous tissue
excess and reduce the volume of the affected extremity,
propagating suction-assisted lipectomy (see Chapter 13).
In recent years many promising results have been published. Brorson reported in a prospective study with 56
patients diagnosed with lymphedema (29 primary and
27 secondary lymphedemas) that the volume of the lower
extremity treated by suction-assisted lipectomy had significantly been reduced after 10 years, but the wearing of
compression garments had to be continued. The same author confirmed his findings in another prospective study,
including 146 breast cancer patients with upper limb
lymphedema. Importantly, risk of suction-associated
damage to the lymphatic vessels has not yet been observed, either experimentally or clinically. In order to
avoid cardiovascular impairment, the author, however,
insists on the shift of electrolytes, and therefore recommends a maximum extraction of 4 liters that should not
be exceeded.
3,4
19.3 New Tools to be Used for
Pre-, Intra-, and Postoperative
Visualization of Lymphatic
Structures
Today, lymphoscintigraphy is still most commonly used
to assess the lymphatic system and therefore considered as the standard procedure. Further technical progresses have allowed to develop various methods,
including three-dimensional imaging techniques and
video-based tools that seem to be superior when compared to lymphoscintigraphy.
is currently used to objectively display in real-time a
precise map of the lymphatics in the layers of derm al
and superficial subcutaneous tissue indicat ing the stage
of lymphedema.
Furthermore, ICG lymphangiography is able to assess
the function of the lymphatic vessels, both qualitatively
and quantitatively, enabling new avenues for diagnosis
and classification. Currently, it delivers accurate data for
preoperative planning, intraoperative assessment of
functionality and vascular patency, and postoperative
follow-up.
lymphatic mapping in order to clearly define which
lymphatic structures need to be saved to best avoid
6,7
It also allows for intraoperative reversed
5
ICG lymphangiography
surgery-induced donor-site lymphedema as well as display lymphatic collectors and/or lymph nodes to be
used as donor tissue
Bioimpedance spectroscopy (BIS) is another rather new
diagnostic tool that that is based on altered electrical conductance of extracellular fluid. BIS is able to accurately
assess the extracellular fluid compartment, particularly
in cases of early-stage lymphedema where structural
changes are not yet present. Unfortunately, accuracy of
BIS decreases with progression of lymphedema.
MRL is currently used to demonstrate the water content within the subcutaneous tissues and under certain
circumstances lymphatic vascularization to map the
course of lymphatics. It is used with or without contrast
media. Moreover, another advantage specific to MRL is
the possibility to create three-dimensional images.
8
(see Chapter 4).
19.4 Lymphoreconstructive Surgery
Improved understanding of the pathophysiological
processes of lymphedema and the continuous amendment of micro- and even supermicrosurgery have
allowed to further develop specific surgical techniques
with a potentially curative approach. They include predominantly LVAs (see Chapter 8), less frequently autol-
ogous lymph vessel transfer (ALVT) (see Chapter 9), and
in par t icular vascularized lymph node transfer (VLNT)
(see Chapter 10). They all have in common the potential to restore physiological lymphatic flow, aiming at
alleviating func tional complaints preventing recurrent
infection and eventually reducing lymphedema stage. If
the outcome is modest, the aim should at least be to
stop the progression of the disease. Ideally, patien ts
undergoing this type of surgery should be able to live
without being dependent on CDT, compression garment included.
The concept of LVAs was first introduced in the 1960s.
Since then, a variety of studies have described the mechanism of function of these physiological bypasses, that is,
the outflow of a low-pressure vascular network of lymphatic vessels into a high-pressure vascular network of
venous vessels following microsurgical anastomosis distal
to the actual lymphatic blockage.
formed under general anesthesia for better patient comfort,
but its execution is also possible under local anesthesia.
Current literature displays a large variety of surgical techniques, number of anastomoses to be performed, and additional procedures that can be offered, including debulking
procedures. The efficacy of LVAs seems to present if a minimum of three anastomoses are performed per affected extremity per patient.
the number of anastomoses is of paramount importance in lymphed ema treatment, no current consensus
is currently available that may predict edema reduct ion
and eventually decrease of tissue excess. Despite the
9,10
12
Usually, LVAs are per-
13
Although many authors claim that
5,11
214
19.4 Lymphoreconstructive Surgery
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descriptionofmanytechniquesofvascularanastomosis
(end-to-end, end-to-side, side-to-end, “octopus,” parachute, and so on), no clear be nef it of one technique over
the other is currently known.
13
This technique is effective with reports of high patient
satisfaction when it comes to edema-associated relief of
symptom and a 35% to 60% reduction in circumference.
About 83% of patients who were assessed using some sort
of extremity index consisting of multiple circumference
measurements at defined anatomical points of reference
on the upper and/or lower extremity showed significant
improvements after LVA surgery. Patient-reported subjective symptom relief, including reduced occurrence of cellulitis (erysipelas) following LVA, ranges from 50% to
100%. Additional surgical debulking have shown to further improve the rate of soft tissue infection and symptom relief reported by the patients. However, all in all the
level of evidence is still rather weak due to small sample
size, heterogeneity, and retrospective character of the
13,14
data
. The currently relevant data are summarized in
▶ Table 19.1 and refer exclusively to the treatment of
secondary lymphedema.
LVA surgery is also a potent tool to reduce episodes of
cellulitis. The relationship between lymphedema and cellulitis episodes is well established. Frequently, cellulitisinduced lymphedema results from the obstruction of
superficial lymphatic vessels caused by tissue inflammation. Tissue inflammation results in fibrotic changes in
the lymphatic vessels and subcutaneous tissue, with subsequent worsening of lymphedema, resulting in a vicious
cycle of lymphatic vessel destruction, lymphedema, and
recurring cellulitis episodes. The restoration of lymphatic
flow back into the circulation and subsequent reduction
in pressure on the lymphatic channels as well as less
stasis are plausible explanations for the reduction of
cellulitis episode frequency.
Hara and colleagues were the only to focus on patients
with primary lymphedema undergoing LVA surgery.
Interestingly, they demonstrated efficacy of technique to
improve postoperative extremity circumference only in
patients over 11 years of age. If operated before that age,
lymphedema symptoms clearly worsened.
15
Another promising microsurgical technique to treat
lymphedema is the transfer of vascularized lymph nodes
(VLNT). In recent years an increase in literature addressing the developing field of VLNT for lymphedema treatment has been noticed. Since the first descriptions aiming
at popularizing the concept of VLNT in lymphedema
treatment, lately a number of studies have demonstrated
promising results, most often popularizing the transfer of
inguinal lymph nodes to treat secondary lymphedema of
the upper extremity following breast cancer treatment.
The concept of VLNT consists of transferring vascularized lymph nodes, usually included into an adipo-fascial,
adipo-dermal, or adipo-cutaneous flap, to the recipient site
of the affected extremity in order to restore lymphatic
drainage function. The detailed physiologic mechanisms
are still speculative. One explanation is that the transferred
lymph nodes act as a sponge to absorb lymphatic fluid,
while another theory suggests that the transferred lymph
nodes induce lymphangiogenesis in order to newly create
lympho-lymphatic and lymphovenous channels and even-
16
tually improve drainage.
A recent review of the literature
evaluated more than 270 VLNTs, mostly performed using
microsurgical techniques. Of interest, follow-up time range
from 1 to 96 months and therefore renders comparability
difficult.
Assessment of postoperative subjective and objective
improvement is usually based on the measurement of
circumference and volumetry, the assessment of functionality and patency of the lymphatics, and quality of
life. A prospective study with a follow-up of more than 3
years revealed significantly greater edema reduction in
patients following VLNT when compared to CDT only.
Another study demonstrated a 24% and 35% reduction in
arm lymphedema and leg lymphedema, respectively, 1
year after VLNT. It is of interest that patients undergoing
VLNT for upper extremity lymphedema report superior
outcomes when compared to those undergoing lymph
node transfer for lower extremity lymphedema
1,17,18
▶ Table 19.2 provides overview of the currently available
relevant data in the field of VLNT.
Iatrogenic lymphedema due to lymph node harvesting
at the donor extremity is a devastating complication.
Careful preoperative assessment of potential donor sites
for lymph node transfer is therefore crucial. A number of
potential donor sites for VLNT have been described, including the inguinal, the submental, the supraclavicular,
the lateral thoracic areas, and the gast roepiploic lymph
nodes (see Chapter 10). Although the inguinal lymph
nodes are most commonly used as a donor site, they are
associated with the highest risk for surgery-induced lymphedema, especially when inguinal nodes are harvested
in the deep tissue layers and medial to the femoral vessels. Furthermore, it is critical to spare the sentinel lymph
node in the groin and axilla for potential oncological reasons. The use of donor sites for VLNT were as follows:
groin (72%; also in combination with microvascular abdominal flap for breast reconstruction), lateral thoracic
area (15%), supraclavicular region (7%), omentum (4%),
and submental region (3%). The supraclavicular and the
submental flaps are not yet well supported by literature,
but their donor sites are associated with a minimal risk of
iatrogenic lymphedema. However, they may have more
obvious scars and potential risks for other important
structures, such as the marginal mandibular nerve during
the harvesting of submental nodes, in addition to variable
anatomy of the pedicle vessels, particularly as concerns
supraclavicular lymph nodes.
Additionally, there is some risk of harming the marginal mandibular branch of the of the facial nerve (submental flap) and the thoracic duct (right supraclavicular flap).
Review of the Current Literature
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Subjective
symptoms
in % of
P-valuesofobjective
Objective
outcomes
in % of
patients
outcomes
patients
(elimination of
compressive
therapy)
(Continued)
LE: 57
74 p = 0.032 UE: 96
Mean
postoperative
follow-up
Measurement
method
Number of
anastomoses/
patient
Type of
surgery
Mean
duration of
lymphedema
Lymphedema
type
time
(months)
(mean)
before
surgery
20.9 100 p < 0.001 44.8
4.4 LEL index and
(months)
18 80 p = 0.04 100
ICG
3.2 Circumference
compressive
treatment
measurement
compressive
treatment
18 65 n/a 95
(optoelectronic
3.5 Volumetry
compression
limb
volumeter)
treatment
UE: 30 LE:
n/a Volumetry
LVA
18.2
(optoelectronic
(n = 35
LE: 79.2
limb
without ICG,
volumeter)
n = 65 with
12 83 p < 0.01 n/a
index and ICG
10 LEL and UEL
ICG)
compressive
treatment
(ICG or along
anatomic
courses of
cephalic vein/
great
7.6 100 p = 0.0003 100
LEL and UEL
index and ICG
”
method)
39
(“octopus
saphenous
vein)
compressive
treatment
(“octopus”
method)
Affected
extremities
Number of
included
extremities
(n)
Numberofincluded
patients
publication
Table 19.1 Overview of the literature on lymphovenous anastomosis in lymphedema surgery
Authors Year of
216
UE and LE SL UE: 42
UE: 89
LE: 11
2013 100 100
Akita et al. 2014 96 192 LE SL 12 LVA +
Auba et al. 2012 10 13 UE and LE PL and SL 110 LVA +
Chang 2010 20 20 UE and LE SL 57.6 LVA +
Chang
et al.
Chen et al. 2016 18 18 UE and LE PL and SL ≥ 6LVA+
Chen et al. 2015 9 9 UE and LE PL and SL 81.6 LVA +
Subjective
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symptoms
in % of
P-valuesofobjective
Objective
outcomes
in % of
Mean
postoperative
follow-up
Measurement
method
patients
outcomes
patients
time
(months)
12 2 n/a n/a
(inverse water
19.4 Lymphoreconstructive Surgery
(Continued)
p = 0.001 n/a
(only in
subgroup
C, n = 22)
20 76
volumetry)
measurement
10 63.8 p < 0.05 100
26.4 47.3 n/a n/a
measurement
and ICG
55.2 55.6 n/a n/a
measurement
p < 0.001 n/a
Mean
pre-op
vs. post-
op: 1.46
vs. 0.18
27.3 100
measurement
episodes
(1 year before
and 1 year
after surgery)
Number of
anastomoses/
patient
Type of
surgery
Mean
duration of
lymphedema
Lymphedema
type
Affected
extremities
Number of
included
extremities
Numberofincluded
(mean)
before
(n)
patients
surgery
(months)
without indigo
≥ 3 Cellulitis
carmine)
compression
treatment
(n = 92), LV A
with excessive
tissue
resection +
compression
treatment
(n=3)
3.5 Volumetry
compression
treatment (7–
10 cm above
elbow)
2 Circumference
with or
without
4.1 Circumference
compressive
treatment
without indigo
n/a Circumference
carmine)
publication
Table 19.1 (Continued) Overview of the literature on lymphovenous anastomosis in lymphedema surgery
Authors Year of
2009 10 11 UE SL 63.6 LVA+
Damstra
et al.
Hara et al. 2015 62 79 LE PL 127.2 LVA (with ICG) 4.5 Circumference
Ito et al. 2016 5 n/a LE PL and SL ≥ 6LVA(withICG)
2000 27 12 UE SL 98.4 LVA (with or
Koshima
2003 25 n/a LE PL and SL 80.4 LVA (with or
et al.
Koshima
2014 95 n/a UE and LE PL and SL n/a LVA+
et al.
Mihara
et al.
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Subjective
symptoms
in % of
patients
P-valuesofobjective
outcomes
Objective
outcomes
in % of
patients
Mean
postoperative
follow-up
time
(months)
Measurement
method
18.3 47.7 n/s 61.5
lymphoscintig-
n/a 75
(LVA only
vs. LVA
plus de-
bulking)
5 19 n/a 66
raphy
(water
displacement)
50.4 44 vs. 60
(water
displacement)
12 53 p = 0.006 n/a
LEL index, ICG
and lympho-
scintigraphy
LEL index 6 100 p < 0.001 n/a
Number of
anastomoses/
patient
Type of
surgery
Mean
duration of
lymphedema
Lymphedema
type
Affected
extremities
Number of
included
extremities
Numberofincluded
(mean)
before
(n)
patients
surgery
n/a ICG and limb
(months)
compression
treatment
conservative
treatment
n/a Volumetry
4Volumetry
(n = 52),
LVA plus
segmental or
radical
reduction
(n = 38)
LVA: 2.1
LVA +
LVA (SEKI): 2
conservative
treatment
41.4 LVA:
63.5
Non-SEATTLE-
LVA: 1.6
SEATTLE-LVA:
1.8
1.7 LEL index 6 100 p < 0.001 n/a
non-SEATTLE,
n = 23), LVA
(with ICG SE-
ATTLE, n = 25)
fied)
publication
Table 19.1 (Continued) Overview of the literature on lymphovenous anastomosis in lymphedema surgery
Authors Year of
218
2016 84 162 LE PL and SL n/a LVA+
Mihara
et al.
1977 62 n/a UE and LE SL n/a LVA+
O'Brien
et al.
1990 90 n/a UE and LE SL 96 LVA only
O'Brien
et al.
Seki et al. 2015 30 30 LE SL LVA-SEKI:
2013 48 n/a LE PL and SL 66 LVA (with ICG
Yamamoto
et al.
2013 14 14 LE SL n/a LVA (modi-
Yamamoto
et al.
Abbreviations: ICG, indocyanine green; LE, lower extremity; LEL, lower extremity lymphedema index; LVA, lymphovenous anastomosis; PL, primary lymphedema; SL, secondary lymphedema; UE, upper
extremity; UEL, upper extremity lymphedema index.
19.4 Lymphoreconstructive Surgery
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Reduction of
lymphedema or
improvement (%)
nonreconstructive
surgery (n)
Measurement method Concomitant
follow-up
time
(months)
6, 8 Lymphoscintigraphy None n/a
Axilla and
< 50% decrease (6)
Return to normal (10),
unchanged (2), > 50%
decrease (6),
Second VLNT ingui-
nal to elbow (7)
lymphoscintigraphy
shoulder (6),
dorsum foot (1)
None 88.9% improvement
lymphoscintigraphy
Axilla 12 Circumference,
40.4%
None 64.9%
alization flap (4)
lymphoscintigraphy
12–54 Circumference Cosmetic deepitheli-
Wrist (8), elbow
(2)
None All improved
lymphoscintigraphy
12 Circumference,
Axilla 4–22 LYMQOL score None 100% improvement
(2)
n/a 1–30 n/a None n/a
8 n/a Excision n/a
Thigh: 6 cm
Hilar perforators (10)
significant difference
(1), lipectomy (2)
Wrist, forearm 23–50 Circumference Debulking surgery
above patella
Knee and groin 5 Circumference None Foot = 86%
Ankle = 57%
Leg = 40%
Knee = 14%
Thigh = 100%
Flap type (n) Recipient site Mean
Number of
included patients
(n) Number of
VLNT flaps
publication
Table 19.2 Overview of the literature on vascularized lymph node transfer (VLNT) in lymphedema surgery
Authors Year of
Attash et al. 2013 4 Pedicle omental flap Groin, lower leg 12 Circumference, volumetry None 50%–75%
node flap (1 free and 6
2014 7 Lateral thoracic lymph
Barreiro
et al.
pedicle)
Becker et al. 2006 24 Inguinal flap Axilla 60 Circumference,
nodes based on SCIV
Chen et al. 2014 10 DIEP with inguinal lymph
SCIV standard (11) and
hilar perforators (10)
node flap (16)
node flap
Fanzio et al. 2011 1 Lateral thoracic lymph
Gharb et al. 2011 21 Inguinal flap based on
lateral thoracic lymph
SCIV
Cheng et al. 2013 10 Inguinal flap based on
Cheng et al. 2012 6 (7) Submental flap Ankle 2–22 Circumference,
Ciudad et al. 2016 6 Free omental flap Ankle (4), wrist
nodes flap based on SIEA
2013 18 DIEP with inguinal lymph
Dancey
et al.
Dayan et al. 2014 35 Inguinal flap (19) and
thoracic lymph node flap
2013 1 (2) Inguinal flap and lateral
Gómez Mar-
tin et al.
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Reduction of
lymphedema or
improvement (%)
nonreconstructive
surgery (n)
Measurement method Concomitant
follow-up
time
(months)
108–113% (1)
50.5% reduction
Wedge excision or
suction-assisted
lipectomy (2)
Lymphoscintigraphy
Axilla 3–33 Volumetry, perometer None 52.4% improvement
None 9.8% reduction
volumetry,
lymphoscintigraphy
None 61%–67%
None 100% improvement
lymphoscintigraphy
lymphoscintigraphy
None 32.2%
lymphoscintigraphy
Axilla 6 Circumference,
Dorsum foot 3–26 n/a Charles procedure 100%
Liposuction (4) n/a
Inguinal, axilla 14–72 Circumference,
n/a
one side
volumetry
Axilla n/a Volumetry None 44%
Flap type (n) Recipient site Mean
Number of
included patients
(n) Number of
VLNT flaps
2014 2 Inguinal flap Axilla n/a Volumetry Liposuction 75%–90% (1),
Granzow
et al.
Table 19.2 (Continued) Overview of the literature on vascularized lymph node transfer (VLNT) in lymphedema surgery
publication
Authors Year of
220
2014 8 Inguinal flap Axilla 18–50 n/a None n/a
Granzow
node flap (14)
lymph nodes
2014 1 LD with lateral thoracic
Vibhakar
et al.
Yeo et al. 2014 1 (2) Supraclavicular flap Ankle bilaterally 1–2 Circumference Charles procedure
Abbreviations: VLNT, autologous lymph node transfer; DIEP, deep inferior epigastric perforator; LD; LYMQOL; SCIV, superficial circumflex iliac vein; SIEA, superficial inferior epigastric artery.
SCIV
2014 24 Supraclavicular flap (13)
Sapountzis
and groin flap (11)
et al.
Vignes et al. 2013 26 (34) Inguinal flap (20) and
dominal free flap
2015 29 Inguinal nodes with ab-
Pons et al. 2013 1 Inguinal flap Axilla 24 Circumference,
Nguyen
et al.
Lin et al. 2009 13 Groin flap based on SCIV Wrist 6–96 Circumference,
et al.
2014 2 Supraclavicular flap (2) Foot dorsum 6–7 Circumference,
Sapountzis
Qiu et al. 2014 1 Submental flap Ankle 3 Circumference,
nodes based on SIEA/
2012 9 DIEP with inguinal lymph
Saaristo
et al.
et al.
lateral thoracic lymph
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