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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. E-mail-D19722@mail.cmuh.org.tw
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.
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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