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Vascularized Groin Lymph Node Flap Transfer for Postmastectomy Upper Limb Lymphedema

The Flap Anatomy, Recipient Sites, and Outcomes

Cheng, Ming-Huei M.D., M.B.A.; Chen, Shin-Cheh M.D.; Henry, Steven L. M.D.; Tan, Bien Keem M.D.; Lin, Miffy Chia-Yu M.Sc.; Huang, Jung-Ju M.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 428e-429e
doi: 10.1097/01.prs.0000438469.29087.49
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Sir:

We thank the authors for their comments on our article, “Vascularized Groin Lymph Node Flap Transfer for Postmastectomy Upper Limb Lymphedema: Flap Anatomy, Recipient Sites, and Outcomes.”1

The deep venous system is not the preferred recipient vessel since the deep veins, the comitant veins of major artery, are usually compressed by the lymphedematous tissue, with positive compartment pressure. The deep veins are usually smaller in the lymphedematous limbs than in the regular limbs. Lorenzo et al.2 addressed that the deep venous system was more reliable than the superficial system in the lower limbs; their study involved injured lower limbs and not lymphedematous lower limbs. That is completely different in terms of recipient vessel selection.

The venous anastomosis was performed underneath the flap and placed on the proximal edge of the flap. The debulking procedure was done 1 year postoperatively on the distal edge of the flap, with removal of partial flap skin and superficial fat. With loupe magnification assistance, the anastomosed cutaneous vein was not injured. Most patients were satisfied with the functional recovery and cosmesis after the debulking procedure.

The hilar perforator of the vascularized groin lymph node flap was used to decrease the debulking procedure and improve cosmesis, as reported by Gharb et al.3 The argument with regard to this issue is whether the skin paddle is necessary when using a vascularized groin lymph node flap transfer. In our opinion, the skin paddle is very important for the release of compartment pressure when the flap is transferred. The vascularized groin lymph node flap is thick, which is difficult to inset into the wrist or forearm pocket without a flap skin paddle. The flap skin paddle could avoid compression of the anastomosed vessels, especially the venous anastomosis inside the fibrotic tissue environment. Without the skin paddle, the transferred lymph node flap may need a skin graft, which will cause severe scar contracture and jeopardize venous return and lymph node function. The skin paddle also quickly established the subdermal lymphatic channels between the native skin and the transferred skin for further lymph drainage.

In summary, we have presented our clinical experience in vascularized groin lymph node flap transfer with careful observation in a long-term follow-up. Many issues remain for further investigation. With more doctors and scientists interested in the field of lymphedema, we may broaden the horizon of treatment for lymphedema patients.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Ming-Huei Cheng, M.D., M.B.A.

Division of Reconstructive Microsurgery

Department of Plastic and Reconstructive Surgery

Chang Gung Memorial Hospital

Shin-Cheh Chen, M.D.

Department of General Surgery

Chang Gung Memorial Hospital

Steven L. Henry, M.D.

Seton Institute of Reconstructive Plastic Surgery

Austin, Texas

Bien Keem Tan, M.D.

Division of Plastic Surgery

Singapore General Hospital

Singapore

Miffy Chia-Yu Lin, M.Sc.

Jung-Ju Huang, M.D.

Division of Reconstructive Microsurgery

Department of Plastic and Reconstructive Surgery

Chang Gung Memorial Hospital

REFERENCES

1. Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: Flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013;131:1286–1298
2. Lorenzo AR, Lin CH, Lin CH, et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: Analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg. 2011;64:649–655
3. Gharb BB, Rampazzo A, Spanio di Spilimbergo S, Xu ES, Chung KP, Chen HC. Vascularized lymph node transfer based on the hilar perforators improves the outcome in upper limb lymphedema. Ann Plast Surg. 2011;67:589–593

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