Page 8 - Read Online

Sarrami et al. Plast Aesthet Res 2024;11:13 https://dx.doi.org/10.20517/2347-9264.2024.06 Page 3 of 15

Table 1. Indications for autologous breast reconstruction with vascularized lymph node transfer

● Delayed breast reconstruction with arm lymphedema
● Immediate breast reconstruction with arm lymphedema
● Revision breast reconstruction following complications associated with arm lymphedema
● > 6 months of conservative management
● > 6 months following radiation therapy

This older lymphography method can also assess the lymphatic flow rate . Additionally, ICG can be useful
[8]
in the lymphedematous limb to map the areas of lymphatic disruption and level of dermal backflow . A
[6,8]
combination of techniques may be required to provide adequate care when planning an autologous flap
with a VLNT.

RECONSTRUCTIVE OPTIONS
Deep inferior epigastric perforator flap with inguinal lymph nodes
The deep inferior epigastric perforator (DIEP) flap remains a reliable and well published autologous option
for breast reconstruction [6,8,13] . With the advent of lymph node transfers, the inguinal nodes became a
common donor for upper extremity lymphedema . This is partially due to the consistent anatomy of the
[5,7]
region and numerous lymph nodes available for harvest [20-22] . Conjoining DIEP flap harvest with inguinal
lymph nodes is the most popular option for patients suffering from BCRL and interested in breast
reconstruction .
[16]

Technical conisderations
This approach was first described by Saaristo et al. . Typically, the nodes can be safely harvested above the
[1]
groin crease, at or below the inguinal ligament, and lateral to the femoral vessels, but this does not
consistently correlate with lymphatic drainage pathways [Figure 1] [8,18] . Reverse lymphatic mapping prior to
incision allows surgeons to navigate the inguinal lymph node basin in real time [Figure 2]. For favorable
inset into the recipient site, the contralateral lymph nodes and ipsilateral deep inferior epigastric artery are
harvested . Flap dissection begins inferiorly, identifying the superficial inferior epigastric perforator and
[16]
the superficial circumflex iliac perforator (SCIP) [13,23] . The inguinal nodes are commonly reliant on the SCIP.
A wide adipofascial margin should be maintained to avoid lymph node devascularization [Figure 3]. The
DIEP flap is then harvested in the usual fashion. Of note, the transverse rectus abdominis myocutaneous
[6,7]
flap can also be used, but it significantly increases donor site morbidity .
The DIEP flap is commonly anastomosed to the internal mammary vessels, but axillary vessels can also be
used when necessary [8,16] . Dissecting recipient axillary vessels also accomplishes scar release which is
recognized as a vital component of lymphedema management . Ideally, the inguinal lymph nodes are inset
[5,7]
in the axilla with an additional anastomosis and vascular supply. The thoracodorsal vessel, or its branches,
provides the best match in both orientation and size. A bipedicle flap may not always be necessary [1,8,23] .
Often, the inguinal nodes maintain adequate perfusion through attachment to the DIEP flap. This can be
assessed using ICG angiography [6,23] . Some recommend separate venous anastomosis for the lymph node
[8]
flap to support lymphatic outflow . Alternatively, the VLNT can be separated entirely from the DIEP flap
[24]
[Figure 4]. This allows for flexibility in DIEP flap positioning and orientation .
Outcomes
The DIEP flap with inguinal lymph node transfer has shown BCRL improvement since its inception. In the
9-patient study originally published by Saaristo et al., 6 had a reduction in upper limb circumference, and of
[1]
the patients who underwent lymphoscintigraphy, 5 of the 6 showed improved lymphatic drainage . These
results were supported by the study from Nguyen et al. of 29 patients who had a mean volume reduction of