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Grünherz et al. Plast Aesthet Res 2023;10:20 https://dx.doi.org/10.20517/2347-9264.2023.24 Page 3 of 8

Figure 1. Treatment algorithm for central lymphatic lesions [35] .

ACQUIRED CENTRAL LYMPHATIC LESIONS
Traumatic interruption of the thoracic duct, either by trauma or more often through surgery within the
neck and mediastinum (e.g. resection of neck and esophageal tumors, heart and aortic surgery, etc.), usually
leads to persistent chyle leaks into wound or body cavities. Often these leaks are not reactive to conservative
therapy alone. Due to the embryology of the central lymphatic system, disruption of lymphatic flow at the
site of the lesion will, in most cases, not lead to downstream congestion, because dual ducts and
spontaneous lympho-venous anastomoses are often present. Therefore, interventional embolization of
traumatic chyle leaks is usually performed as a first-line therapy [Figure 1]. However, if a cutaneous chyle
fistula drains via an open wound, reconstructive surgery can be considered during wound revision. In
addition, interventional treatment may not be possible due to the absence of the cisterna chyli. In recent
years an increasing number of reports have demonstrated that central lymphatic lesions causing severe
chylothorax and chylous ascites can be successfully treated by thoracic duct-vein anastomosis in the
retroperitoneal area and at the neck, depending on the location of the chyle leak [24,26-30] . Alternatively,
chylous ascites can be treated by a deep inferior epigastric-based lymphatic cable flap connected to a
gastroepiploic lymphnode flap. The latter may offer a new approach for patients with severe refractory
chylous ascites .
[31]

Previously, we treated a 52-year-old patient with a thoracic duct fistula after left modified radical neck
dissection for hypopharyngeal carcinoma and lymphogenic metastasis. The patient had also received
neoadjuvant radio-chemotherapy. The diagnosis of thoracic duct injury was made on the basis of a
postoperative milky drainage secretion of 50-170 ml/24 h and confirmed by the assessment of chylomicrons