Page 66 - Read Online

Hosomi et al. Plast Aesthet Res 2023;10:60 https://dx.doi.org/10.20517/2347-9264.2023.77 Page 3 of 8

from the hand to the axilla. We performed LVA at two locations on the affected limb, one on the ulnar side
of the forearm and one on the medial side of the upper arm. Both were performed with end-to-end
anastomosis. Intraoperatively, her lymphatic vessels were found to be severely sclerotic, with no lymphatic
flow observed. Although the previous lymphatic vessels were found to be patent, there was no identifiable
flow through these anastomoses upon exploration. No significant improvement in UEL was observed after
the LVA on 18 months follow-up [Figure 1], and the decision was made to perform free flap transplantation
with VLNT and additional efferent lymphatic vessel anastomosis.

Surgical technique
Preoperative ICG lower limb lymphography was performed and the limb lymphatic vessel flow and the
location of the groin lymphatic nodes marked [Figure 2]. Surgery was performed under general anesthesia,
with the left groin area used as the VLNT donor site. A skin incision was made along the inguinal ligament,
and the superficial circumflex iliac artery (SCIA) and vein (SCIV) were dissected. A single lymph node
supplied by the proximal SCIA was identified. The feeding artery and vein to the lymph node were
confirmed and preserved using a microscope. Both vessels were less than 0.5 mm in diameter. The efferent
lymphatic vessel from the node was detected and marked with a vessel clip. ICG and patent blue were then
injected into the lateral abdominal region around the posterior superior iliac spine, and the peripheral
lymphatic vessels running towards the inguinal lymph node were detected and marked with vessel clips
[Figure 2]. A 25 cm × 4 cm fasciocutaneous SCIP flap, including the efferent lymphatic vessel, the lymph
node, and the peripheral afferent lymphatic vessels, was designed and harvested based on the superficial
branch of the SCIA as a perforator flap [Figure 3]. The efferent lymphatic from the lymph node was
transected at the point of the deep fascia. At least two superficial inguinal lymph nodes were preserved to
avoid postoperative lymphedema at the donor site. The flap was transferred to the right thoracic region. The
distal end of the flap was inserted in the axilla region and the proximal end inserted in the internal
mammary region [Figure 3]. A medial intercostal artery perforator (ICAP) arising from the internal
mammary artery in the 2nd intercostal space was prepared as a recipient vessel without any resection of
costal cartilage. The ICAP artery (0.8 mm diameter) and accompanying vein (2.0 mm) were anastomosed to
the SCIA (0.7 mm) and SCIV (1.5 mm), respectively, in an end-to-end fashion using 10-0 nylon.

To reconstruct physiological lymph flow, the efferent lymphatic vessel of the VLNT SCIP flap was
preserved. ICG was injected above the 6th rib and an internal mammary collecting lymphatic vessel (0.4
mm) was detected running adjacent to the internal mammary artery [Figure 4]. This was anastomosed to
the efferent lymphatic vessel (0.5 mm) of the lymph node in the flap using the intravascular stent (IVaS)
technique in an end-to-side fashion using 11-0 nylon [Figure 4].
[13]

The proximal skin of the flap was deepithelialized and adipose tissue including the lymphatic vessels was set
under the right breast region and used for augmentation of the breast, leaving a 2 cm × 1 cm distal skin
island to be used for flap monitoring.

Postoperative care
Postoperative recovery was uneventful, the wounds healed well, and compression dressing was restarted at
two weeks. Postoperatively, her right arm UEL index gradually reduced [Table 1]. On review at 24 months
postoperative, the UEL index of the affected upper extremity was improved to 134 from 141. Postoperative
ICG lymphography showed lymphatic flow from the right extremity to the distal portion of the transferred
flap and through the transferred flap to the right internal mammary region [Figure 5]. This indicated the
flow of lymphatic fluid from the upper extremity draining into the internal mammary lymphatic system
through this flap. The flap donor site healed well with no morbidity and no lower limb lymphedema. No
episodes of cellulitis of the affected right upper limb were reported following flap transfer and the patient
was extremely satisfied with the result. The total follow-up duration was 2 years.