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Page 6 of 9 Tawaklna et al. Plast Aesthet Res 2023;10:63 https://dx.doi.org/10.20517/2347-9264.2023.40

used to massage the lymphedematous limb in the proximal-to-distal direction beginning 1 month after
[18]
VLNT to the ankle . Compared to a group of patients receiving only complete decongestive therapy,
patients in this cohort experienced significantly greater decrease in limb circumference and increase in
lymphedema-specific quality of life. Ciudad et al. were able to achieve a mean circumference reduction rate
of 22.3% when performing VLNT to the ankle .
[31]
The main disadvantage of the distal recipient site is that there is limited laxity and space to accommodate
the lymph node flap, necessitating a skin paddle or, more uncommonly, skin graft. This results in poor
cosmesis and interference with footwear and compression garment [Table 1]. There is higher incidence of
venous complications with VLNT to the ankle, even with the use of a skin paddle. Koide et al. reported a
significant decrease in flap exploration and total complication rates with the use of delayed primary
retention sutures, which are placed at the time of the lymph node transfer but can be loosened or tightened
at the bedside in the immediate post-operative period . Fortunately, with close flap monitoring, the
[30]
majority of venous insufficiency cases can be salvaged and do not appear to compromise long-term
functional outcomes of the procedure . At 6-12 months post-operative, the skin paddle can often be
[28]
removed in its entirety, after subsidence of edema and increased pliability of peri-lymph node flap
tissues [1,16] .

Middle lower extremity: mid-thigh, popliteal fossa, & medial calf
The mid-anterior thigh, popliteal fossa, and the medial calf have been described as recipient sites for VLNT
to the mid lower extremity [9,10,27] . The most popular recipient vessels are the lateral circumflex femoral and
the medial sural; the descending genicular is infrequently mentioned, and no detailed description of its
surgical technique is provided in the literature.

Positioned in between the proximal and the distal recipient options, the mid lower extremity recipients
blend many of the characteristics of their neighboring regions. For example, they are spared from the scar
tissue and fibrosis of the groin and proximal thigh while having enough potential space to accommodate the
lymph node flap without a skin paddle or graft-albeit with considerable debulking of the adjacent
subcutaneous fat and medial gastrocnemius muscle. Because neither the lateral circumflex femoral nor the
medial sural artery provides in-line flow to the distal extremity, there is no concern for distal perfusion.
Lastly, its relative proximity to the pooled lymph fluid allows the transferred lymph nodes to fulfill their
function as a lymphovenous shunt. Although not statistically significant, Manrique et al. showed a mean
excess volume reduction of 23.3% when inset in mid-thigh vs. a reduction of 13.3% when inset at the
[10]
ankle . Furthermore, patient reported function scores; however, those who had mid extremity inset had
significantly shorter hospital stay, faster return to daily activities and higher satisfaction with surgical scar
and appearance [Table 1] .
[10]

A notable modification to the VLNT technique features the use of omental lymph nodes as a flowthrough
flap with the right gastroepiploic artery anastomosed to the proximal end of the divided medial sural artery
and the left gastroepiploic artery anastomosed to the distal medial sural artery . The flap is also
[9]
supercharged by anastomosing the right gastroepiploic vein to one of the venae comitantes of the medial
sural artery and the left gastroepiploic vein to the lesser saphenous vein. While this configuration
theoretically minimizes the risk for venous hypertension by both reducing arterial inflow and augmenting
venous outflow, long-term follow up data has not yet been reported.

Preferred protocol
At our high-volume institution, the author’s preferred protocol begins with lymphoscintigraphy to assess
the extent and severity of lymphedema in the affected limb. After the patient has been deemed an