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Page 2 of 8 Danforth et al. Plast Aesthet Res 2021;8:48 https://dx.doi.org/10.20517/2347-9264.2021.34

The standard treatment for lymphedema involves a combination of compression and physical therapy.
These modalities have been repeatedly shown to decrease limb volume when performed correctly. However,
[1]
they require strict, long-term compliance and, unfortunately, do not provide complete relief . Given these
issues with non-invasive options, surgical therapies for lymphedema have been developed and show
promise when standard options are inadequate.

Surgical treatments fall into two categories, debulking procedures and physiologic procedures aimed at
restoring lymphatic function. Advances in microsurgery and super-microsurgery have allowed for
[2-4]
significant progress in the physiologic category . Vascularized lymph node transfer (VLNT) uses the
microsurgical technique to transfer functioning lymph nodes to the affected limb with the goal of restoring
lymphatic drainage. There are two main theories to explain how vascularized lymph node transfers improve
lymphatic function. First, some suggest that the lymph node flap serves as a “wick” or a bridge that re-
connects the distal to the proximal functional lymphatics, thus restoring drainage. The second theory is that
the lymph nodes collect interstitial fluid and “pump” it into the systemic circulation via the lymphovenous
connection within the node .
[5]
Since the development of VLNT, surgeons have sought the ideal donor lymph node basin. The most utilized
donor sites in the literature are the groin, axilla, and supraclavicular nodes. However, a major concern with
the harvest of the groin or axillary nodes is developing a secondary, iatrogenic site of lymphedema . While
[6,7]
reverse lymphatic mapping helps to mitigate this risk , many surgeons are still hesitant to use these sites or
[8]
do not readily have access to reverse mapping. On the other hand, supraclavicular and submental lymph
node harvests are criticized for the highly visible scar locations.

In our institution, we prefer the use of intraabdominal lymph nodes for VLNT. The most significant
advantage of these donor sites is that they carry no risk of iatrogenic lymphedema. Furthermore, they can be
combined safely with each other and be performed simultaneously with other procedures such as
autologous breast reconstruction [9,10] . Additionally, the scars from a mini-laparotomy, low transverse
incision, or laparoscopic port sites are well hidden. This will discuss the reported techniques, outcomes, and
complications for omental, jejunal, and appendiceal lymph node donor sites.

OMENTAL LYMPH NODE TRANSFER
The high concentration of lymphatic tissue in the omentum makes it a desirable donor for VLNT. One of
the first descriptions of a physiologic operation for lymphedema was the use of a pedicled omental flap,
[11]
originally published in 1966 . The omentum was raised on the right gastroepiploic vessels and then
tunneled extra-peritoneally to the affected limb. However, this technique never gained widespread
popularity, likely due to the hernia created in the tunneling process. The advances and increased availability
of microsurgery have led to renewed interest in the omental transfer for lymphedema treatment in the form
of a free tissue transfer. Although they are mostly small single-center case series, numerous studies have
shown positive results and improved lymphedema symptoms following vascularized omental lymph node
transfers [9,12-15] . Studies with quantitative limb measurement outcomes are summarized in Table 1.

One major advantage of the omental flap is the familiarity of the dissection for most reconstructive
surgeons. The reliable length and caliber of the gastroepiploic pedicle, the large size of the omentum, and
the high density of lymph nodes allow for a variety of technical options when using the omental lymph
node basin as a VLNT donor . One potentially beneficial feature of the omentum is that it often has large
[21]
and easily visible lymphatic channels. Upon transfer, these channels can be used for primary anastomoses of
afferent lymphatics to augment the lymphatic function of the VLNT. Several modifications of the omental