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Page 4 of 16 Raman et al. Plast Aesthet Res 2023;10:6 https://dx.doi.org/10.20517/2347-9264.2022.62

platform. Missing variances were imputed using the prognostic method described by Ma et al., substituting
[20]
mean variances for the missing values .
RESULTS
Summary of articles
Using the standardized search strategy, 1,301 studies with relevant titles and abstracts were retrieved from
all databases. A total of 751 duplicate records were deleted after applying a deduplication process , and 550
[21]
citations were then imported into the project library. One further duplicate article was removed using
Covidence.org. A total of 77 full-text investigations initially met the inclusion criteria for this study. Upon
further review, 11 studies reporting the same outcomes from the same population were identified and
removed. Ultimately, 66 studies were included in the systematic review. The selection process is described in
a flowchart [Figure 1].

The ASPS level of evidence for these articles ranged from Level II to Level IV [Table 1]. The majority of
[16]
the studies (42 out of 66, 63.6%) were retrospective [Table 1].

Several staging scales were used to assess the severity of lymphedema. The most commonly used was the
International Society of Lymphology scale (30 articles, 45.5%). A large subset (22 out of 66, 33.3%) did not
use any imaging for staging [Table 1].

Out of all studies, 8 unique donor sites were identified: groin, submental, omentum, supraclavicular, lateral
thoracic, appendicular, ileocecal, and jejunal mesenteric. Of note, twenty studies evaluated numerous VLNT
donor sites in their investigation. Over half of all included studies (38 out of 66, 57.6%) addressed groin
VLNT, followed by 20 (30.3%) which addressed omental, 14 (21.2%) submental, 13 (19.7%) supraclavicular,
9 (13.6%) lateral thoracic, and 2 (3.0%) each for appendicular and ileocecal, and 1 (1.5%) jejunal mesenteric.
One article (1.5%) had a donor site from the neck region but was unclear about the specific flap utilized. The
earliest investigations from our systematic review identify the groin VLNT as the initial donor site that
propelled forward the era of VLNT. From 2010-2020, outcome-based research related to submental,
supraclavicular, lateral thoracic, and jejunal mesenteric donor sites was published. The latest additions to
VLNT within the past 5 years included additional intra-abdominal donor sites, such as appendicular and
ileocecal.

Patient-reported outcomes using validated questionnaires were addressed in 16 (24.2%) of the
investigations. These outcomes were most frequently from studies addressing groin, submental, and
omental VLNT, while jejunal mesenteric, appendicular, and ileocecal VLNT had no articles addressing
PROs for patients. Most studies (71.2%) reported on recipient-site complications, while 68.1% reported on
donor complications.

Patient demographics
There were a total of 2316 patients and 2376 VLNTs reported in the 66 articles [Table 2]. It should be noted
that not all investigations reported every patient demographic characteristic. Out of the studies reporting
the gender of the patients, the majority of patients were female (63.9%). Overall, the mean age of patients
was 54.0 ± 5.4 years and the mean BMI was 27.2 ± 2.5. Most of the patients (79.4%) had a secondary cause of
lymphedema [Table 2]. Patients experienced symptoms for 51.1 ± 34.1 months prior to their surgery.

Large subsets of the overall sample received groin (26.1%) or omental (20.2%) flaps. Fewer received jejunal
mesenteric, appendicular, and ileocecal VLNTs. More patients were treated for upper extremity