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Tawaklna et al. Plast Aesthet Res 2023;10:63 https://dx.doi.org/10.20517/2347-9264.2023.40 Page 7 of 9

appropriate candidate, the authors favor an omental flap to the middle lower extremity for the following
reasons: abundance of lymphatic tissue, proximity to pooled lymph fluid, and avoidance of added bulk or
poor cosmesis of the distal lower extremity.

Post-operatively, patients are monitored according to standard free tissue transfer protocols including
frequent doppler checks and clinical perfusion assessment. For the first 48 hours after surgery, the patient is
kept on strict bed rest with leg elevation and careful positioning to prevent pressure on the flap. If the
vascularized nodes are transferred to the groin, hip flexion is limited to 90 degrees and the knee is splinted
in extension. If a distal recipient site is chosen, the ankle is splinted in a neutral position and a dangle
protocol is initiated after 48 hours. Patients are typically discharged to home 3-5 days after surgery. The first
therapy visit takes place two weeks after surgery at which point range of motion restrictions are lifted.
Manual lymphatic drainage (MLD) is initiated with care to avoid the flap and to remain one palm-width
away from incisions. Wrapping is allowed distal to the transferred nodes only. At four weeks post-
operatively, MLD is initiated throughout the extremity, including over the flap, and wrapping restrictions
are lifted.

While this represents the authors’ currently favored protocol, multiple suitable regimens likely exist, and a
compelling case can be made for other lymph node transfers and multiple recipient options. Some recipient
[4]
sites result in less morbidity and more acceptable scars . Etiology and patient history should also be
considered when determining optimal recipient site. For example, circumstances such as radiation, trauma,
and prior surgery can eliminate options depending on the location, timing, or severity. Some recipient sites
may be more effective in draining distal disease while proximal sites are more effective proximal in treating
proximal disease [7,10] . Notably, no direct comparison data are available for analysis and represents a
necessary area for future research.

CONCLUSION
Early data support the practice of vascularized lymph node transfer in carefully selected patients with lower
extremity lymphedema. Many questions remain unanswered, including the ideal recipient location for the
lymph node flap. A compelling case can be made for each of the three options, but no direct comparison
data are available for analysis. It may be that no one recipient site fits all patients with lower extremity
lymphedema, and the decision should be individualized to each patient.

DECLARATIONS
Authors’ contributions
Made substantial contributions to study conception, design of study, performed data gathering, analysis,
interpretation, and creation and revision of the manuscript: Bruce JG, Ha AY
Made substantial contributions to data gathering, analysis, and interpretation, and creation and revision of
the manuscript: Chi D, Tawaklna K
Made substantial contributions to study conception, design of study, performed data analysis and
interpretation, revision of the manuscript, and provided administrative, technical, and material support:
Anolik R

Availability of data and materials
Not applicable.