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Page 10 of 15 Sarrami et al. Plast Aesthet Res 2024;11:13 https://dx.doi.org/10.20517/2347-9264.2024.06

Vascularized omentum lymphatic transplant
In plastic surgery, the omental flap has been utilized for its neovascularization and immunologic function in
[37]
many surgical situations . Goldsmith first described its role in lymphedema treatment in the 1960s, and
it has been utilized for various lymphatic disruptions since that time [38,39] . In BCRL specifically, the
omental flap has been useful in improving lymphatic flow and filling the dead space within the axilla [5,40] .
This flap can be used alone to create aesthetically contoured breast or easily combined with other breast
reconstruction options [41,42] . Nguyen et al. have shown promising results at complete autologous
reconstruction, utilizing the omental flap in an acellular dermal matrix (ADM) pocket following skin-
sparing or nipple-sparing mastectomy .
[43]

Technical conisderations
The omental flap is based on the gastroepiploic vessels which should be mapped preoperatively to ensure
[5]
sufficient vascularity . The flap is harvested laparoscopically and is a flat and malleable tissue. To increase
flap volume, Nguyen et al. describe intra-flap fat grafting through direct visualization [37,43] . This is
particularly useful when dividing the omental flap for bilateral reconstructions. The omentum is then placed
in an ADM pocket which has been contoured around a saline breast sizer [37,44] . A medial opening is
constructed for the pedicle, and a lateral opening allows for the vascularized lymph nodes to be positioned
in the axilla. The gastroepiploic vessels are anastomosed to the internal mammary artery and the flap is inset
in the mastectomy breast pocket . Nguyen et al. favor immediate reconstruction after skin-sparing or
[44]
nipple-sparing mastectomy, but delayed reconstruction with a tissue expander is also viable [37,43] .

Outcomes
Small case series using the omental flap for complete breast reconstruction have been published by
Nguyen et al. [43,44] . Their group has shown great cosmetic results with good symmetry in patients with
smaller breasts. In their 3-patient study outlining their surgical technique for immediate breast
reconstruction with omental flap fat grafting, patients reported satisfaction based on BREAST-Q
questionnaires . A similar study from their group assessed omental flap use in BCRL patients; however,
[43]
reconstruction with and without abdominal-based free flaps was included. In this 7-patient case series, there
was a wide range of arm volume reduction from 0%-77% at about 10 months postop . In a larger
[44]
systematic review of omental lymph node transfer for upper extremity lymphedema by Jarvis et al., the
volume reduction ranged from 22.7% to 39.5%. There was also noted improvement in patient-reported
outcomes and a reduction in cellulitis episodes postoperatively .
[45]

Benefits
The omental flap has shown reliability in several surgical situations and has been well published as a
treatment method for lymphatic disorders . In the current literature, there has been no reported
[37]
occurrence of donor site lymphedema or lymphatic disruption following omental flap harvest [5,46] . This has
made it a very attractive option for lymphatic reconstruction in recent years.

Pitfalls
Despite the use of a laparoscopic approach, there are still many associated risks of intra-abdominal surgery
in addition to free flap transfer. In a systematic review by Jarvis et al. assessing omental flap use for upper
[45]
extremity lymphedema with a total of 91 patients, the complication rate was 17.6% . Most complications
were minor, though there were some reports of flap compromise and loss, ileus, transient pancreatitis, and
infection . There is also a risk of converting to an open operation and creating a large unaesthetic scar .
[5]
[45]
Additionally, estimating the size of the omentum is difficult prior to surgery and the tissue has been
criticized for being too small for total breast reconstruction [41,43] . Nguyen also note that the malleable tissue