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Guiotto et al. Plast Aesthet Res 2023;10:26 https://dx.doi.org/10.20517/2347-9264.2023.15 Page 11 of 14

Figure 4. Clinical outcomes before (A) and after (B) debulking surgery + MLVA for a stage III Genital Lymphoedema.

Figure 5. Lymphoscintigraphy pre (A) and post (B) for the second patient of our series: (A) preoperative condition; (B) Postoperative
improvement of right lymphatic flow and disappearance of scrotal dermal backflow after three MLVAs at the right groin. TI = 12 preop
and TI = 2 post-op.

The second option in terms of physiological treatment of GL is vascularised lymph node transfers (VLNT).
This is another microsurgical technique, which consists of a lymphatic soft tissue free flap transposition
[37]
from a donor site such as the groin, chest wall, neck or omentum to the affected lymphoedematous area .
Considering the concern of iatrogenic lymphoedema in the donor site [3,38] in this series, the omentum was
the flap transfer of choice [39,40] .

When derivative procedures are not sufficient as isolated procedures , we propose the combination of
[41]
LVA/MLVA with VLNT. For instance, in the first patient of our series, we first performed a lymphatic LV
shunt, and secondly, due to the partial blockage resolution at the level of the scrotum, but the persistence of
penile oedema, an omental VLNT was performed.

Limitations
This study has some limitations, mainly related to the type of study: being a multicenter one, diagnosis,
clinical evaluation, surgery, and follow-up were performed by three different consultants; this can lead to a
significant bias in data analysis, interpretation and hard comparability. Moreover, the outcomes evaluation
was predominately qualitative due to the lack of systematic postoperative lymphoscintigraphy or other
quantitate parameters. Finally, the retrospective nature of the study and the number of patients represent