LETTER TO THE EDITOR MICROSURGERY 00:1–3 (2014) RIGHT GASTROEPIPLOIC LYMPH NODE FLAP Dear Sir, Vascularized lymph node flap transfer (VLNFT) is a tissue transfer procedure of high interest for the treatment of lymphedema. VLNFT is a new approach for treating lymphedema and during the last few years it is becoming more popular.1 Different donor sites for VLNFT including groin, supraclavicular, submental, thoracodorsal artery have been described. Herein, we present the results of the successful surgical management of six patients suffering from upper (2) and lower (4) limb lymphedema using a novel vascularized lymph node flap based on the right gastroepiploic (R-GE) vessels. To our knowledge, this is the first report using an intra-abdominal lymph node flap to treat lymphedema. The flap was based on the R-GE artery and vein. Harvest of the flap was performed through an upper midline laparotomy incision. The first step was to identify the right gastroepiploic vessels, then omentum was carefully dissected off the transverse colon with great care not to injure the mesocolon. The left gastroepiploic vessels were then divided and dissection of the short segmental gastric branches allowed the release of the flap from the stomach and permitted complete visualization of the R-GE vessels. Dissection was carried to the level of the right epiploic vessels. The lymph nodes within the flap cannot always be visualized but they often can be palpable. Indocyanine green lymphatic imaging could be performed to confirm the vascularity of the lymph nodes included within the flap. *Correspondence to: Hung-Chi Chen, MD, PhD, 2 Yuh-Der Road, Taichung, Taiwan 40447. [email protected] Received 16 June 2014; Revision accepted 18 September 2014; Accepted 10 October 2014 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22344 Ó 2014 Wiley Periodicals, Inc. All patients underwent preoperative assessment, including photographs, circumference measurement, lymphoscintigraphy, and skin tonicity measurement. Microsurgical anastomoses were performed using the medial plantar vessels end-to-end and the radial artery for endto-side anastomosis of lower and upper limb lymphedema respectively (Fig. 1). A suction drain was left in situ at the donor-site for 6 days. Patients were discharged on the tenth post-operative day. Post-operative follow-up was performed every 3 months during the first year. After 1 year follow-up all patients exhibited significant improvement and were satisfied with the functional and aesthetic results. Lymphoscintigraphy was performed and improvement was seen in all cases. No post-operative episodes of cellulitis or other complications were observed during the follow-up period. This flap has two mechanisms of function: one is the physiological lymphatic drainage from the interstitium to the vascularized lymph node flap and then into the pedicle vein,2 and the second is through its ability to absorb the lymphatic fluid by the omentum tissue adjacent to the vascular pedicle.3 Advantages of the use of this flap include the large diameter of the gastroepipolic vessels, minimal donor-site morbidity, no concern of causing iatrogenic lymphedema, and allowing a two-team approach. This flap contains omentum tissue around the pedicle that will also help in the absorption of lymphatic fluid by the affected limb. The use of laparoscopy to harvest the flap could offer a minimal insult to the abdominal wall and ensures a short and comfortable post-operative recovery period. The main disadvantage of the use of this flap includes the laparotomy required to access the lymph nodes with all of its potential complications. 2 Letter to the Editor Figure 1. A: Preoperative marking of the right gastroepiploic lymph node flap. B: Right gastroepiploic lymph node flap and surrounding omental tissue containing lymph node. C, D: Inset of the lymph node flap in upper and lower limb lymphedema. One lymph node was visible at the distal part of the flap. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] In lymph node flap transfer surgery, donor-site morbidity has always been a source of concern for the surgeons and patients since it is always possible for the patient to develop iatrogenic lymphedema, lymphorrea, or another unexpected complication at the donor-site. Each of the lymph node flaps described has its own advantages and disadvantages; the selection should be made by the microsurgeon and should be individualized for each patient. Although the series presented herein is not large, none of our patients experienced any problems at their donor-sites. KIDAKORN KIRANANTAWAT, F.R.C.S.(T), M.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan STAMATIS SAPOUNTZIS, M.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan MATTHEW SZE-WEI YEO, F.A.M.S.(PLAST), M.R.C.S.ED., M.MED., M.B.B.S., D.F.D. PEDRO CIUDAD, M.D. Department of Plastic and Department of Plastic and Reconstructive Surgery Reconstructive Surgery China Medical University Hospital China Medical University Hospital Taichung, Taiwan Taichung, Taiwan Tissue Engineering and Regenerative FABIO NICOLI, M.D. Department of Plastic and Medicine Program Reconstructive Surgery National Chung Hsing University Taichung, Taiwan China Medical University Hospital Taichung, Taiwan Microsurgery DOI 10.1002/micr Letter to the Editor MICHELE MARUCCIA, M.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan PORNTHEP SIRIMAHACHAIYAKUL, M.D. Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan HUNG-CHI CHEN, M.D., PH.D., F.A.C.S.* Department of Plastic and Reconstructive Surgery China Medical University Hospital Taichung, Taiwan 3 REFERENCES 1. Sapountzis S, Ciudad P, Lim SY, Kiranantawat K, Nicoli F, Constantinides J, Wei MY, S€ onmez TT, Singhal D, Chen HC. Modified Charles procedure and lymph node flap transfer for advanced lower extremity lymphedema. Microsurgery 2014;34:439–447. 2. Cheng MH, Huang JJ, Wu CW, Yang CY, Lin CY, Henry SL, Kolios L. The mechanism of vascularized lymph node transfer for lymphedema: Natural lymphaticovenous drainage. Plast Reconstr Surg 2014; 133:192. 3. Egorov YS, Abalmasov KG, Ivanov KG, Abramov YA, Gainolin RM, ChatterJee SS, Khussainov BE. Autotransplantation of the great omentum in the treatment of chronic lymphedema. Lymphology 1994;27:137–143. Microsurgery DOI 10.1002/micr
© Copyright 2024