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Page 6 of 9 Minasian et al. Plast Aesthet Res 2022;9:18 https://dx.doi.org/10.20517/2347-9264.2021.128

[26]
symptomatology, rather than restoring lymphatic physiology . With regard to PTL treatment specifically,
debulking is only mentioned by one study in conjunction with vascularized lymph node transfer (VLNT) as
[36]
a first stage procedure, to optimize the local environment one month in advance of VLNT .

Lymphovenous anastomosis
Lymphovenous anastomosis (LVA) has been described for a case of intractable ulcer with lymphorrhea in
[19]
the setting of post-traumatic and obesity-induced lymphedema . Lymphovenous anastomosis bypasses
obstructed lymphatic channels by connecting patent upstream lymphatics to nearby, low-pressure
[37]
subdermal veins and shunting fluid directly into the venous system . This supermicrosurgical technique
demands dedicated instruments for handling 11-0 or 12-0 suture and a surgeon’s tactile sense to detect the
[35]
[38]
intima of the vessels and the lymphatic flow . Multiple LVAs are usually required . In this case, the
patient was treated with 3 LVAs distal to the ulcer site, and experienced resolution of the lymphorrhea and
[19]
ulceration 2 weeks later without recurrence . A single LVA was also described to treat isolated penile
lymphedema without recurrence of swelling despite complete removal of compressive garments at 6
[27]
months .
VLNT
VLNT, also called autologous lymph node transplantation, is another physiologic method of lymphatic
reconstruction. A recipient site is prepared within the lymphedematous area by excision of scar tissue.
Recipient vessels are dissected and prepared for anastomosis. A small lymph node-containing free flap is
harvested from a donor site while ensuring that the harvest does not cause donor site lymphedema. The
lymph node packet is anastomosed to the recipient blood vessels without any direct lymphatic
[35]
anastomosis . The transferred nodes initially act as a “wick” via their afferent lymphatic channels, which
partially drain into the efferent vein of each node . They also secrete lymphangiogenic growth factors,
[39]
[38]
including VEGF-C, which promote the ingrowth of new lymphatic channels over time . The excision of
scar tissue likely contributes to successful outcomes by clearing the site of obstruction to lymphatic
[35]
regeneration . VLNT donor sites include the supraclavicular, submental, groin, lateral thoracic, and
omental lymph nodes [40,41] . The selection of donor site is dictated primarily by minimizing morbidity .
[42]
Donor site complications specific to VLNT include lymphocele, lymphatic fistula, and lymphedema of
[44]
donor limb . Donor site iatrogenic lymphedema can be reduced using reverse lymphatic mapping ,
[43]
which uses technetium-99 sulfur colloid and ICG to distinguish between lymph nodes draining the trunk
and those draining the extremities.
There are three descriptions of VLNT for the treatment of PTL. One used groin node flaps to treat two
[36]
patients with PTL of the upper extremity (one burn and one blunt force trauma) . Both patients were
treated in a staged manner one month following extrafascial dermolipectomy and local advancement flaps,
and experienced improvement. The other two studies are case reports using chimeric lateral thoracic nodes
with thoracodorsal system flaps in patients with lower extremity PTL. In one case, the flap also included a
fasciocutaneous thoracodorsal artery perforator flap . The second case incorporated a latissimus and split
[41]
serratus flap due to the presence of more than one defect .
[45]
Lymphatic vessel free flap
Lymphatic vessel free flap (LVFF) is the most recent form of physiologic lymphatic reconstruction applied
to PTL [4,46] . The technique of LVFF was first described by Yamamoto et al. in 2018. It involves free tissue
[47]
transfer in which no lymph nodes are harvested. However, lymphatic channels are purposefully included
and transplanted with the flap in order to bypass lymphatic blockages and restore lymphatic flow at the
recipient site. By designing the flap in regions with high lymphatic channel density, such as the groin,
lymphatic channels are reliably included. Supermicrosurgical anastomosis is not required, but the axial ends