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Page 2 of 10 Skladman et al. Plast Aesthet Res 2023;10:66 https://dx.doi.org/10.20517/2347-9264.2022.107

INTRODUCTION
Lymphedema is a progressive condition, caused by the failure of the lymphatic drainage system, resulting in
the excessive retention of lymphatic fluid in the interstitial compartment. The estimated prevalence of
lymphedema varies widely based on etiology, gender, and age of onset. The etiology of lymphedema can be
divided into primary or secondary lymphedema. Primary lymphedema is rare, and 30% of patients have a
[1]
genetic mutation-most commonly a mutation of the vascular endothelial growth factor signaling pathway .
The prevalence is 1 in 100,000 individuals and most often presents during childhood, affecting the lower
extremities, but sparing the arms and genitalia. 1 Secondary lymphedema accounts for 99% of reported
cases, and worldwide the most common cause is filariasis .
[1]
Most cases of lymphedema amenable to surgical management are caused by an insult to the lymphatic
system which may be infectious, traumatic, or as a result of malignancy or its treatment . The most
[2]
common etiology is breast cancer- related lymphedema (BCRL) secondary to lymphatic dissection during
extirpative surgery. Axillary lymph node dissection impairs lymphatic drainage and is the biggest risk factor
for developing BCRL. Radiation therapy increases the risk of developing BCRL since radiation induces
fibrosis of lymph nodes and damage to lymphatics in the dermis . A systematic review of 72 studies found
[3]
that the pooled incidence of upper extremity lymphedema among breast cancer survivors is 17% . A meta-
[4]
analysis of non-breast malignancies found an overall lymphedema incidence of 16%, with an incidence of
20% in the lower extremity and an incidence of 5% in the upper extremity . Regardless of cancer type,
[5]
lymphadenectomy is the strongest predictor of lymphedema .
[5]
Congestion of lymphatic fluid causes chronic inflammation, leading to fibrosis and further damage to the
lymphatic vessels. Persistent lymphatic stasis decreases oxygen tension, causing inflammation and reactive
tissue fibrosis, cellular proliferation, and fat deposition. Clinically, patients experience progressive swelling,
pain, numbness, and tingling [1,2,6-8] . Eventually, patients develop hypertrophy, acanthosis, and hyperkeratosis
that results in skin breakdown [1,2,7] . In rare cases, lymphedema progresses to elephantiasis nostras verrucose
in which the skin over the affected area has warty, hyperkeratotic, “mossy” or “cobblestoned” appearance
and is prone to ulcers and fissures. A feared consequence of lymphedema is the development of cellulitis,
lymphangitis, and lymphatic malignancies . Lymphedema is associated with a decreased quality of life,
[3]
embarrassment due to cosmesis of the affected limb, and financial burden. Patients report a decreased
ability to perform activities of daily living and maintain employment [9,10] .

VASCULARIZED OMENTAL LYMPH NODE TRANSFER
VLNT
The International Society of Lymphology has developed a staging system based on clinical exam and
volume differences between the affected and unaffected extremity . For patients with advanced
[11]
lymphedema, (ISL stages II-III), VLNT is a physiologic procedure that has been shown to decrease limb
volume and improve symptoms of lymphedema [12,13] . During this procedure, healthy lymph nodes, along
with their vascular supply, are transferred to the affected area. The newly transplanted lymph nodes act as a
[14]
sponge to absorb lymphatic fluid and direct it into the vascular system . Furthermore, these lymph nodes
secrete growth factors that stimulate the generation of new lymphatic vessels at the site of disease.
Vascularized lymph node transfer typically utilizes groin, thoracic, submental and supraclavicular nodes.
However, concerns about iatrogenic donor site lymphedema at donor sites remain. VOLT has come into
favor due to negligible donor site lymphedema and the immunologic properties of the omentum-such as the
abundance of lymph nodes and milky spots-which makes it particularly favorable for patients with
lymphedema associated with cellulitis or recurrent infections [15-18] . Thus, the purpose of this report is to
describe the utility of the VOLT for the treatment of lymphedema, its relevant anatomy, and harvest