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Skladman et al. Plast Aesthet Res 2023;10:66 https://dx.doi.org/10.20517/2347-9264.2022.107 Page 5 of 10

efferent lymphatic vessels [15,16] . In their series of 42 patients, Nguyen et al. found that the incidence of
[16]
cellulitis decreased from 74% preoperatively to 5% after omental transfer . As a result, they have modified
their clinical algorithm such that patients with a history of recurrent infections receive the vascularized
[17]
omentum flap .

Another benefit is that the omental lymphatic flap can be both a VLNT and lymphovenous anastomosis as
[16]
it brings both gastric lymph nodes and a lymphatic efferent vessel to the affected site . The efferent
lymphatic vessel runs alongside the gastroepiploic vessels, and can be directly anastomosed to a recipient
[16]
venule for a better anatomic and physiologic reconstruction .
Di Taranto et al., have begun to use laparoscopic free omental tissue containing gastroepiploic lymph nodes
to treat patients with lower extremity ulcers secondary to severe lymphedema . The free omental
[31]
lymphatic flap brings highly vascularized tissue to cover the defect with the added benefit of bringing in
plenty of lymph nodes to improve the lymphatic networks of the affected limb. In their 10 patients, they
report no further episodes of infection with a significant decrease in the frequency of cellulitis, decreased
circumference, improved quality of life, and complete healing of the wound following surgery .
[31]
Furthermore, all patients had improved lymphatic drainage on lymphoscintigraphy and new lymphatic
vessels could be detected at the site of the flap, demonstrating the lymphangiogenic properties of the
[31]
omentum flap .
Of importance, lymph nodes in the omentum are not crucial to drainage of the donor site, thus avoiding the
risk of inducing iatrogenic lymphedema at the donor site [14-16,26] . While, the submental and supraclavicular
lymph node flaps are also less likely to cause donor site lymphedema, unsightly scars and potential damage
to the marginal mandibular nerve are of concern . Thus, the omentum flap is useful for patients who have
[26]
previously underwent an unsuccessful lymph node transfer, or who have limited donor sites due to prior
surgery or radiation [14,26,31] . Following omental flap transfer, studies have reported an upper extremity
circumference reduction from 9%-22.2% and a reduction in lower extremity circumference from 50%-75%
with a 2%-29% differential improvement in volumetric measurements .
[31]

As mentioned, due to its large surface area and longitudinal pedicle, the omentum provides enough
lymphatic tissue to be split into two flaps to allow dual level lymph node transfer, to both proximal and
distal extremity sites [14,32] [Figure 2A and B]. This can be particularly advantageous if there are two sites or an
entire extremity affected, or if scar release and dead space management are necessary at the
lymphadenectomy site but there is a separate area with the most edema. Often, the most affected portion of
the limb will be the distal aspect, even if the lymphadenectomy was proximal [14,17] .

There are several disadvantages of VOLT that must be addressed. The first group of disadvantages stem
from invasion of the abdominal cavity. Intra-abdominal complications include adhesions, bowel
obstruction, incisional hernia, postoperative abdominal pain, and pancreatitis-a rare complication
associated with VOLT [14,16,26,29,31] . Harvesting the flap off the left gastroepiploics may cause injury to the
spleen due to vessels that are difficult to identify, but this complication may be avoided by harvesting the
right-side omentum [33,34] . The second group of complications arise due to the anatomy of the gastroepiploic
vessels. These vessels are thinner than those associated with other vascularized lymph node transfer harvest
sites making them more prone to kinking . Furthermore, Kenworthy et al. have noted significant venous
[31]
[14]
hypertension after conventional anastomosis of the primary artery and vein when using the VOLT flap .
Thus, they routinely perform a second anastomosis of the distal gastroepiploic vein to a second recipient
[14]
vein . Finally, it should be noted that VOLT may be contraindicated in patients with a history of multiple