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Page 2 of 13 Rajaram et al. Plast Aesthet Res. 2025;12:6 https://dx.doi.org/10.20517/2347-9264.2024.147

grafting in humans.

Keywords: Lymphoedema, plastic surgery, microsurgery, cancer

INTRODUCTION
Lymphoedema is a common and debilitating sequala of cancer management. The disruption of lymphatic
drainage due to surgical division or radiotherapy-induced destruction of lymphatic pathways leads to a
deficit in lymphatic drainage. Seen most commonly in the limbs and increasingly in the head and neck, the
swelling in lymphoedema is distinct from vasogenic oedema due to its potential to form into solid fibro-
fatty infiltrates with time . The International Society of Lymphology encapsulates this natural history in a
[1]
clinical staging system ranging from stage 0 to stage 3, with increasing swelling and fibrosis as patients
[2]
ascend the stages . As such, the effective management of lymphoedema is not focused on fluid balance but
rather is centred around bolstering lymphatic clearance.

Currently, the armamentarium of lymphoedema management modalities can be divided into surgical and
non-surgical options. The cornerstone of non-surgical management is complete decongestive therapy
(CDT). This physiotherapy technique combines compressive garment wear and manual lymphatic drainage
and has seen modest yet reproducible success, with the restrictive requirement of daily patient adherence .
[3]
Surgical management of lymphoedema offers patients a significant reduction in swelling associated with
lymphoedema and the potential restoration of lymphatic drainage . Lymphoedema surgery is broadly
[4]
divided into reductive and physiological modalities. The frontier of lymphoedema surgery focuses on the
physiological restoration of the lymphatic drainage deficit through techniques such as lymphaticovenous
anastomosis (LVA) and vascularised lymph node transplant (VLNT) .
[4]

In particular, VLNT has gained popularity due to its ability to facilitate improvements in advanced and
otherwise recalcitrant lymphoedema . The technique involves performing free tissue transfer with local
[4]
lymph nodes resected and transferred en bloc. While effective, the technique is a complex microsurgical
procedure imposing surgical morbidity and the cardiorespiratory burden of a general anaesthetic on
[4]
patients, many of whom already have superimposed co-morbidities .

In light of this, non-vascularised lymph node transfer (NVLNT), a surgical technique for inducing
lymphangiogenesis without the operative burden of microsurgical anastomosis, is currently being explored
in animal and human studies. In essence, NVLNT is a procedure by which lymph nodes are harvested from
a distant site, such as the groin or axilla, and are grafted onto the lymphedematous site . Emerging animal
[5]
studies suggest that grafted lymph nodes can undergo lymphangiogenesis at a distant site even without the
substantial donor blood supply provided by a flap . NVLNT could, therefore, be a surgical modality to
[6]
reverse the pathophysiology of later-stage lymphoedema without the considerable operative burden of
VLNT, making effective lymphoedema management accessible to a wider cohort of patients. This article
will explore the biology, surgical methodology, and current animal and human evidence base for the efficacy
of NVLNT to date. It will endeavour to offer the current sum of research on this emerging lymphoedema
management technique.

METHODS
A systematic search of PubMed, Embase, and Scopus databases was performed from their inception until
December 2023. The search strategy utilised a combination of relevant keywords and MeSH terms. The
following search terms were used (Lymph node gra OR Lymph node transfer OR avascular lymph node
*