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Page 10 of 13 Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70

for the vascularised lymph node flaps. The vascularised lymph node flap is done distally in the limb and
anastomosed to vessels around the ankle and the wrist. This helps to reduce the worsening distal oedema
[68]
and recurrent cellulitis of the limbs .

RADICAL REDUCTION OF LYMPHOEDEMA WITH PRESERVATION OF PERFORATORS
With knowledge of the anatomical position of the perforators of the limb and with various investigations
such as handheld Doppler and CT scan, we are able to raise flaps with better vascularity. This helps us to
excise tissue more confidently leaving behind good vascularised tissue. Accordingly, incisions in the limbs
are made, and flaps based on the perforators are raised, while the excess tissue is radically removed. In the
upper limb, the blood supply of the tissue left behind is based on the perforators from the brachial artery
in the arm and from the radial, ulnar and posterior interosseous artery perforators. In the lower limb, the
blood supply of the tissue left behind is mainly from the posterior tibial artery and peroneal artery. This
[69]
technique is particularly useful for lower limb lymphoedema (52% reduction) compared to upper limb
[70]
lymphoedema (15% reduction) .

CONCLUSION
The management of lymphoedema is an evolving science. Every patient with lymphoedema needs a
detailed clinical evaluation, which may include investigations such as ICG lymphangiography to decide
upon the best treatment. Understanding the benefits and limitations of various procedures will help us
choose the optimal line of management for every patient. The results could be very gratifying both to the
patient and the surgeon.

DECLARATIONS
Authors’ contributions
Lead surgeon: Venkatramani H
Preparation of manuscript and collection of data: Shanmugakrishnan RR
Assistant surgeon participated in most of the surgeries: Kumaran MS
Correction of manuscript and scientific advice: Sabapathy SR

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Ethical approval obtained from the institutional review board (IRB). Written consent was obtained from all
patients to take photographs and use their data for publication.

Consent for publication
The authors give consent for publication. Photographic consent was obtained for all patients.

Copyright
© The Author(s) 2020.