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Page 4 of 10 Park et al. Plast Aesthet Res 2023;10:40 https://dx.doi.org/10.20517/2347-9264.2022.98

These three donor sites are primarily used due to minimal donor-site complications and reduced operation
time. Other studies have proposed that LVA and VLNT be performed in a staged or staggered fashion due
to the long operation time. However, the aforementioned donor sites allow lymph node harvest to be
[18]
performed simultaneously with LVA since the operative fields do not overlap . As a result, the addition of
LVA does not significantly elongate the operation time compared to VLNT alone.

Omental flap
The omental flap's biggest advantage is the low possibility of iatrogenic lymphedema. Compared to
supraclavicular, submental, or groin flaps that can cause iatrogenic lymphedema or chyle leak, iatrogenic
lymphedema has not been reported after the omental flap harvest . However, some disadvantages are the
[19]
need for intra-abdominal surgery, its associated complications, and possibly conspicuous abdominal scars.
Additionally, harvesting lymph nodes in a relatively unfamiliar area can be a hurdle for plastic surgeons. At
our institution, we overcome these pitfalls by cooperating with general surgeons specializing in laparoscopic
gastrointestinal surgery. After harvesting the flap through a single port in the umbilicus, the flap is inset in
the scar-released axilla [Figure 3].

Another benefit of the omental flap is its abundance of lymph nodes. Along the omental arcade, numerous
lymph nodes exist. In their cadaveric study of ten adults without gastric disease, Borchard et al. reported an
[20]
average of 14.9 ± 14.1 lymph nodes along the greater curvature . This contrasts with 6.2 ± 1.3 lymph nodes
found in 10 × 5 cm groin flaps in another cadaveric study by Cheng et al. .
[21]
Combined breast reconstruction with DIEP and lymph node transfer
Early reports have shown the benefit of immediate breast reconstruction in reducing the occurrence of
BCRL . However, the lymphedema-reducing benefit of autologous tissue-based breast reconstruction
[22]
without concurrent lymph node transfer has been debated [22-24] . On the other hand, simultaneous VLNT and
breast reconstruction have shown promising results [25-28] .

Therefore, in BCRL patients seeking delayed breast reconstruction, combined breast reconstruction using
DIEP flap and SIEA-based lymph node flap can be an excellent option to restore the breast and improve
BCRL symptoms.

Similar to omental harvest, LVA can be performed in the arm while DIEP and lymph node flap is harvested
in the abdomen to reduce operation time. While DIEA is used as the feeding vessel for the perforator flap,
SCIA is used as the feeding vessel for the groin lymph nodes. DIEA is anastomosed to the internal
mammary artery (IMA), and SIEA/SCIA is anastomosed to the thoracodorsal artery. SCIA and the lymph
node can be harvested either ipsilateral or contralateral to the DIEA . In our experience, using the
[29]
contralateral SIEA minimizes kinking of the DIEA pedicle. If the inset proves difficult, the SIEA/SCIA-
based lymph node can be separated from the DIEP flap for easier anastomosis and inset.

SCIP flap
In patients who do not want delayed breast reconstruction and are at increased risk of complications from
abdominal surgery (e.g., previous surgery, peritonitis, etc.), SCIA-based VLNT flap is another possible
option. The main advantages of SCIP flap are inconspicuous scar, well-known anatomy of the vasculature
[30]
and the lymphatic drainage, and the ability to provide a large skin paddle when needed .

SCIP flap has limited donor site morbidity and is a familiar free flap for most microsurgeons. One major
disadvantage of the SCIP flap is the possibility of iatrogenic lymphedema, which will be discussed in the