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Minasian et al. Plast Aesthet Res 2022;9:18 https://dx.doi.org/10.20517/2347-9264.2021.128 Page 7 of 9

of respective donor and recipient lymphatic vessels must be in close proximity to achieve
[47]
lymphangiogenesis . Lymphatic vessel free flaps may provide the advantage of decreased risk of donor site
lymphedema compared to VLNT and carry them skin for soft tissue resurfacing.

The initial report of LVFF in PTL was a case of upper extremity lymphedema secondary to degloving injury,
treated with superficial circumflex iliac artery perforator lymphatic vessel (SCIP-LV) flap . There was
[46]
clinical improvement within two weeks and a 55% reduction of excess limb volume at four months, with
ICG uptake into the flap. A follow-up study included 11 patients who received SCIP-LV flaps to prevent (n
[4]
= 6) or treat (n = 5) PTL . In the PTL treatment group, the mean reduction of excess limb volume was 63%,
and quality of life improved by 51%. No patients in the prevention group developed PTL.

SUGGESTED DIAGNOSTIC AND TREATMENT PRACTICES
Reconstructive surgeons should recognize critical lymphatic areas and keep these regions in mind as
susceptible to lymphatic injury when evaluating trauma patients. Even small insults without massive trauma
in a critical area should prompt close surveillance, with quick initiation of appropriate workup and
treatment as needed.

Workup for PTL should include ICG lymphography. The diagnostic gold standard, lymphoscintigraphy,
can be normal in the setting of localized or superficial lymphatic dysfunction, which can be seen in PTL.
ICG lymphography provides real-time visualization of the superficial lymphatics, allowing precise diagnosis
and optimizing surgical planning.

PTL treatment should be individualized per patient exam and ICG findings. All patients with PTL should be
initiated early with conservative measures including compression and CDT. When reconstructing extremity
defects, one should take into account critical lymphatic areas and choose options which are least disruptive
to lymphatic function. Additionally, immediate reconstructive approaches can be tailored to include a
lymphatic component, such as immediate LVA or a flap which contains nodes or lymphatic vessels. For late
presentations with non-pitting or mixed presentations, liposuction can be added before, after, or
concomitantly with these physiologic procedures .
[48]

CONCLUSION
Post-traumatic lymphedema is a complex, debilitating, and potentially common disease which has received
limited attention to date. Awareness of injury to critical anatomic areas may help the reconstructive surgeon
prevent lymphedema in the acute phase via surgical or nonsurgical techniques. Wider awareness of PTL and
understanding of appropriate workup may facilitate earlier identification of these patients. Following
diagnosis, treatment should be tailored to each patient depending on their needs, with a focus on restoring
lymphatic physiology. Prospective and comparative studies are necessary to determine the incidence of PTL,
as well as the optimal strategies for prevention and treatment.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study, drafting and revisions, as well as
performed data acquisition, analysis and interpretation: Minasian RA, Brazio PS
Made substantial contributions to data acquisition, analysis, and interpretation, as well as drafting of
manuscript: Samaha Y