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Page 2 of 16 Raman et al. Plast Aesthet Res 2023;10:6 https://dx.doi.org/10.20517/2347-9264.2022.62

not uniformly reported.

Conclusion: This meta-analysis identified that intra-abdominal donor sites have the potential to reduce
postoperative infectious episodes more than extra-abdominal donor sites. Though recent investigations address
many understudied VLNT donor sites, larger comparative studies and a standardized methodology are needed to
better characterize postoperative outcomes, which can offer more concrete evidence to guide surgical practice.

Keywords: Lymphedema, vascularized lymph node transfer, lymphedema surgery

INTRODUCTION
Lymphedema is a chronic condition characterized by the accumulation of protein-rich lymphatic fluid
[1]
within the interstitium, leading to swelling of the affected limb and overlying skin and tissue changes .
Lymphedema can result in significant functional and psychological morbidity for patients, as it can be
[2-5]
disfiguring, lead to infection, and limit the range of motion . Regardless of disease severity, conservative
treatment remains a cornerstone of management . The main conservative treatments involve complete
[6,7]
[7]
decongestive therapy (CDT), compression bandages, exercise, and meticulous skin care .
In some patients, surgical options may be of benefit. Amongst these options, lymphovenous anastomosis
(LVA) and vascularized lymph node transfer (VLNT) have become increasingly popularized in recent
years . LVA involves the creation of a shunt between a high-pressure lymphatic system and a lower-
[6,7]
pressure venule system, allowing for increased lymph drainage . Vascularized lymph node transfer is
[8]
theorized to operate through a different mechanism: the lymph nodes act like a “pump”, siphoning lymph
from the surrounding tissues and draining through natural lymphovenous anastomoses within the flap [9,10] .

Since its introduction, VLNTs have expanded to involve various novel donor sites . Apart from the groin,
[11]
where VLNT was initially described, supraclavicular, submental, lateral thoracic, omental, and jejunal
mesenteric lymph node flaps have also been reported . More research is needed to clarify the outcomes for
[11]
upper and lower extremity lymphedema following the use of each of these donor sites. This systematic
review thus presents the current evidence regarding clinical and patient-reported outcomes (PROs) based
on these various VLNT donor sites and identifies gaps in the literature.

METHODS
A literature search was performed using a combination of keywords and controlled vocabulary in
Embase.com 1947-, Ovid Medline 1946-, Scopus 1823-, The Cochrane Database of Systematic Reviews
(CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov 1997-. The
search strategy encompassed variations of terminology, including synonyms and differences in spelling, and
was agreed upon by the authors of this review. All search strategies were completed on November 12, 2021,
with no added limits. Fully reproducible search strategies for each database can be found in the Appendix
[Supplementary Table 1]. All search strategies and written methodology were created using the standards
and guidelines for conducting and reporting systematic reviews set forth by the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA), the National Academies (IOM) Standards for
Systematic Reviews, the Cochrane Handbook of Systematic Reviews, and Peer Review of Systematic Search
Strategies (PRESS) [12-15] .

The articles obtained from the search were uploaded to Covidence. Studies were included if they adhered to
the following criteria: (1) included at least 5 patients aged 18 years or older; (2) addressed VLNT;