Page 53 - Read Online

Page 4 of 9 Tawaklna et al. Plast Aesthet Res 2023;10:63 https://dx.doi.org/10.20517/2347-9264.2023.40

reducing the severity of upper and lower extremity lymphedema; however, this review did not include
[2]
subgroup analysis comparing outcomes across the different recipient sites . The only published review that
specifically examined this distinction found that VLNT to the ankle was associated with greater reduction in
limb volume and higher proportion of functioning lymph node flaps on post-operative imaging when
compared to VLNT to the groin or proximal thigh . Unfortunately, it was not completed as a formal
[18]
systematic review or meta-analysis.

There have been, however, some studies published examining the outcomes between distal and proximal
insets in the upper extremity. Chocron et al. performed a systematic review of lymph node transfer in breast
cancer-related lymphedema comparing inset at the wrist to inset at the axilla. Their results showed no
[19]
significant difference circumference reduction rate or excess volume reduction . While including a large
patient population, their analysis did not delineate changes in the arm vs. forearm. Cheng et al. showed
some evidence that a distal inset is more likely to improve distal lymphedema. They found that there was a
significant improvement in circumferential differentiation and circumferential reduction rate specifically
below the elbow when lymph nodes are inset at the wrist vs. inset at the elbow . Although their sample size
[16]
was small, this may lend credence to directing recipient site based on the areas more severely affected by
lymphedema.

Ultimately, the choice of recipient site must be individualized to each patient for the best outcome. There
are a number of options that each possess advanatages and disadvantages that can help delineate surgical
decision making [Table 1]. Multiple factors should be considered, including but not limited to the etiology,
severity and location of lymphedema, availability of recipient vessels, prior surgery and/or radiation, the
patient’s concern for final aesthetic appearance, and the surgeon’s experience with individual recipient
sites .
[1,3]

Proximal lower extremity: groin & proximal thigh
Proximal recipient sites for VLNT to the lower extremity include the groin and the proximal thigh. Many
recipient vessels have been described for this region, including branches of the external iliac (deep inferior
epigastric, deep circumflex iliac) and the common femoral (superficial femoral, profunda femoris,
superficial inferior epigastric, superficial circumflex iliac, lateral circumflex femoral) [20,21] . The pedicle to the
profunda artery perforator has also been reported as a potential recipient .
[22]
The main advantage of this recipient site is that the dense scar and fibrosis from prior surgery and/or
radiation are removed as part of the recipient bed preparation [3,4,23] , which by itself may improve lymphatic
and venous drainage. The transfer of a well-vascularized lymph node flap can then maintain the pliability of
soft tissues in the region as well as aid in lymphatic drainage via lymphangiogenesis [24,25] . An early animal
study demonstrated that transfer of lymph nodes to a lymph node-depleted area-such as the groin after
pelvic lymphadenectomy and radiotherapy-restored lymphatic flow, but new transferred nodes did not
induce lymphangiogenesis in normal uninjured areas [24,25] . Additional advantages include the ability to easily
hide surgical scars with clothing and the relatively ample potential space to accommodate the lymph node
flap without significant compression on the pedicle [Table 1] . Moon et al. showed a mean volume
[4]
[26]
decrease of 13% when performing VLNT to the proximal thigh .
The main disadvantages of the proximal recipient site are that the heavy scar burden often makes the
dissection challenging, tedious, and unpredictable . In rare cases in which there is no recipient vessel to
[27]
allow for a superficial placement of the lymph node flap, vein grafts may be required [Table 1] .
[4]