This study revealed that lymph flows could be restored after tissue replantation or free flap transfer without supermicrosurgical lymphatic vessel anastomosis or lymph node transfer. Lymph flow seemed to be restored by connection between lymphatic vessels that originally existed in an amputee/flap and a recipient site, not by development of new lymph pathways. In replantation cases, lymph flow restoration was observed except for one case with raw surface in lymph axiality. Because lymph axiality between amputee and recipient site is usually matched in replantation cases, only scar formation attributable to raw surface area seems to interrupt lymph flow restoration by means of lymphangiogenesis.23 , 24 Among free flap transfer cases, lymph flow restoration was observed only in cases with compatible lymph axiality. When there is no compatible lymph axiality, lymphangiogenesis is considered insufficient to connect distant lymphatic vessels between a recipient site and a flap. As shown in Table 4, lymph axiality plays a critical role in lymph flow restoration after tissue replantation or transfer.
If a raw region remains around the lymphatics in an amputee or a flap, formation of scar tissue around the lymphatics inhibits lymph flow restoration.7 , 9 , 10 If the direction of the lymph flow is not in line with the existing flow proximal and/or distal to the defect, lymph flow restoration is less likely to occur. Because previous studies suggested that lymphangiogenesis may occur after wound healing with width of few centimeters, we used 2-cm as a cutoff value of raw surface in lymph axiality and compatible lymph axiality.1 , 8 , 12 , 13 , 15 , 19 It is noteworthy that lymph node is not necessary to restore lymph flows when proximal and distal ends of lymphatic vessels in a defect can be bridged using lymphatic vessels included in a flap.
In replantation cases and toe transfer cases, compatible lymph axiality can be relatively easily achieved, because lymphatic vessels are known to exist in the midlateral aspect of the digits.15 , 26–28 However, as shown in Table 2, compatible lymph axiality is hardly achieved in skin flap transfer cases other than toe flap transfer cases when indocyanine green lymphography is not used for assistance. Indocyanine green lymphography guidance is essential to achieve compatible lymph axiality, but is not possible in all cases. Because the primary objective of skin flap transfer is coverage of a defect, compatible lymph axiality can be achieved only when inset of a flap does not affect defect coverage.
This study revealed other factors associated with postoperative lymph flow restoration. Male sex, defect caused by trauma, and replantation cases were associated with a higher lymph flow restoration rate. In this study cohort, more male and trauma cases were included in the replantation group. This can be explained by the fact that replantation cases were associated with a higher rate of positive compatible lymph axiality and lymph flow restoration, but further studies are required to clarify independent factors associated with lymph flow restoration with a larger sample size, allowing multivariate analysis.
Prolonged edema sometimes affects postoperative rehabilitation, and can even develop as clinically significant lymphedema after replantation surgery or free flap transfer, as shown in Figure 2.5 , 8 , 11 , 12 Once manifested, lymphedema progresses over time and significantly deteriorates a patient’s quality of life.4 , 5 , 8 , 10 , 29–32 Based on the results of this study, a reconstructive surgeon can restore lymph flows without a lymph node flap or supermicrosurgical lymphatic anastomosis; lymph flows can be restored when tissue is replanted/transferred with compatible lymph axiality without raw surface in lymph axiality. Lymph axiality-based tissue transfer has a potential to allow more physiologic reconstruction, facilitates postoperative rehabilitation, and prevents lymphedema even when main lymph pathways are damaged.
One of the limitations of the study is that only a relatively small number of Japanese patients were included without long-term follow-up. It is unclear whether this study’s results can be applicable for non-Japanese cases or whether the lymph axiality-based tissue transfer method is clinically useful to prevent lymphedema in long-term follow-up. Most importantly, the lymph axiality-based tissue transfer has yet to be clarified as being useful for the treatment of established lymphedema. Theoretically, lymph axiality-based tissue transfer seems to restore arm lymph flows of patients with upper extremity lymphedema after axillary lymph node dissection, by transferring a skin flap at the axilla with compatible lymph axiality without lymph node inclusion or supermicrosurgical lymphatic anastomosis. Although supermicrosurgical lymphatic vessel anastomosis allows secure restoration of lymph flows, supermicrosurgical technique is required, which can be performed only by experienced microsurgeons; secure anastomosis technique for vessels with diameter of 0.5 mm or smaller is required for supermicrosurgery.13 , 16 , 33 Because lymphedema treatment with vascularized lymph node transfer has a risk of donor-site lymphedema, lymph axiality-based tissue transfer can be a useful therapeutic option for compression-refractory lymphedema, with a minimum risk of donor-site lymphedema.25 , 33–36 Further prospective studies including a larger number of cases with longer clinical follow-up are required to confirm the importance of lymph axiality in lymph flow restoration, to confirm the usefulness of lymph axiality-based tissue transfer in prevention and treatment of lymphedema, and to evaluate which flap is more useful for lymph axiality-based tissue transfer.
Lymph flows can be restored after tissue replantation or free flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. Lymph axiality–based tissue transfer, replanting/transferring tissue with compatible lymph axiality without raw surface in lymph axiality, is considered a key for lymph flow restoration.
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