Complete lymph flow reconstruction: A free vascularized lymph node true perforator flap transfer with efferent lymphaticolymphatic anastomosis

https://doi.org/10.1016/j.bjps.2016.06.028Get rights and content

Summary

Treatment of primary lower extremity lymphedema (LEL) is challenging, and lymph node transfer (LNT) can be a choice of treatment for progressive LEL. However, LNT has a risk of donor site lymphedema and possible lymph node (LN) sclerosis due to efferent lymphatic vessel (ELV) obstruction. Here, we report the first case of complete lymph flow reconstruction with true perforator LNT with efferent lymphaticolymphatic anastomosis (ELLA) for a patient with primary LEL and severe lymphosclerosis. A 49-year-old female suffered from primary progressive unilateral left LEL refractory to conservative treatments with frequent episodes of cellulitis. A true perforator LN flap was selectively harvested from the left lateral thoracic region under indocyanine green (ICG) lymphography navigation and transferred to the left groin with perforator-to-perforator anastomosis. The ELV of the transplanted LN was supermicrosurgically anastomosed to the contralateral iliac lymphatic vessel that was subcutaneously transferred to the left groin. Postoperatively, the patient experienced no episode of cellulitis with reduced degree of compression treatment, and lymphedematous volume decreased from 306 to 264 in terms of LEL index. Postoperative ICG lymphography showed evidence of reconstructed lymph flow from the left foot to the left groin and to the right inguinal LN through the transplanted LN flap and the ELLA. There were no subjective or objective findings of donor site lymphedema of the left arm or the right back and the lower extremity. True perforator LN flap with ELLA is a safe and effective treatment and has the potential to be a useful therapeutic option for primary unilateral LEL.

Section snippets

Case report

A 49-year-old female had suffered from idiopathic left lower extremity edema for the past 5 years. Edema began at the age of 44 years without any causative episode and since then had gradually worsened. The patient experienced frequent episodes of left leg cellulitis since she was 45 years old. She was not under medication and had no medical history or family history of edematous diseases. Heart failure, nephrosis, liver cirrhosis, deep venous thrombosis, varix, endocrine diseases,

Discussion

This case revealed that complete lymph flow reconstruction was possible by transferring a true perforator LN flap and ELLA using an intact recipient lymphatic vessel from a nonaffected region, which was confirmed with postoperative ICG lymphography. Unlike conventional LNT methods that can decongest lymph only through an LN's drainage vein, our method allows physiological lymph flow reconstruction through both an LN's ELV and a drainage vein.23, 24 Since lymph drained into an LN flows out

Disclaimers and disclosure

None.

Ethics

This case was reported under the University of Tokyo Hospital ethics committee- and Tokyo Metropolitan Bokutoh Hospital ethics committee-approved protocol.

Funding

None.

Conflict of interest

None declared.

Acknowledgments

The author (T.Y.) thanks Rico for support in preparation of the manuscript.

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    Prior presentations: This article was presented in 1) part at the 3rd International Symposium on Lymphedema Surgical Treatment, Barcelona, Spain, March 5, 2014, and 2) at the 25th International Society of Lymphology Congress, San Francisco, USA, September 10, 2015.

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