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Raman et al. Plast Aesthet Res 2023;10:6 https://dx.doi.org/10.20517/2347-9264.2022.62 Page 13 of 16

be well-hidden [48,49] .

[49]
The most common intra-abdominal flap is derived from the omentum . The omentum is highly
vascularized and large in size, with large lymphatic channels, and lymphatic lakes, which make it a
potentially ideal donor site candidate [48-50] . While VLNTs from other intra-abdominal donor sites like the
ileocecum and appendix are being explored, currently, there is limited data on the efficacy and safety of
these specific flaps.

The literature overall reveals the potential for improved outcomes with intra-abdominal flaps. On average,
patients who received intra-abdominal flaps had significantly fewer episodes of infection postoperatively.
This is likely due to the great angiogenic and immunomodulatory potential of the omentum . However,
[51]
despite the absence of iatrogenic lymphedema in patients who received intra-abdominal flaps, omental
VLNT had the highest rate of recipient-site complications and one of the highest donor-site complication
rates reported. Concerning donor-site complications, intra-abdominal sources of lymph nodes possess
[35]
unique risks that are inherent with these procedures, such as ventral hernias and small bowel obstruction .
Overall, when interpreting these results, it should be noted that since few studies specifically reported
complications, it is likely that the true frequency of many complications for both extra-abdominal and intra-
abdominal flaps was not captured.

While the current research on intra-abdominal VLNT donor sites is promising, it is still unclear whether the
benefits are significant enough to overcome the additional risks that come with intra-abdominal surgery.
More research needs to be done on the efficacy of intra-abdominal flaps, especially the non-omental intra-
abdominal sites, and techniques refined and standardized to minimize the risk of donor-site complications.

Patient-reported outcomes
The inclusion of patient-reported measures is crucial in analyzing outcomes of lymphedema treatment.
Previous studies have shown that the severity of limb edema may not correlate with the amount of change
in patient-reported outcomes, as patients can report significant impairments even when volume changes
may not be evident [52-54] . Unfortunately, the vast majority of studies (50 articles out of 66, 75.8%) in this
systematic review did not include any patient-reported outcomes using validated questionnaires/scales. For
the studies that did address PROs, the lack of standardization in reporting the results made it difficult to
compare these outcomes across studies. This was likely due to the fact that earlier studies often used non-
[52]
validated tools or non-lymphedema-specific tools . However, once the LYMQOL scale was validated in
2010, it became the most commonly used tool . Using this scale, there is a trend toward patients who
[52]
received omental flaps reporting the greatest improvement in LYMQOL scores, while those who received
lateral thoracic flaps had the least improvement. Interestingly, patients with lateral thoracic flaps also had
the highest rate of donor site complications, which could potentially explain the reduced postoperative
PROs scores for lateral thoracic VLNT.

The LYMQOL showed greater improvement in scores in functional, appearance, symptom, and mood
domains for patients who underwent VLNT for upper limb lymphedema, but the overall quality of life
improved more after VLNT to the lower extremity.

Limitations
Limitations of the present study should be recognized. Inconsistent reporting of data, as well as significant
heterogeneity of study design and methodology, prevented meta-analysis with many of the reported
outcomes. Additionally, small sample sizes for some VLNT donor sites could have impacted statistical