Vascularized Groin Lymph Node Flap Transfer for Postmastectomy Upper Limb Lymphedema

EDITORIAL COMMENT

As a last gasp technique for failed lymphedema patients, this technique looks like a reasonable procedure to try. It might be best to insert the flap in the axilla, allowing for lymphatic drainage from the entire upper extremity.

Historically, it was Clodius (1) who first reported vascularized groin lymph node (VGLN) flaps to treat extremity lymphedema. Further studies by Chen et al. (2) in a canine model and later by Tobbia et al. (3) in a sheep model demonstrated the basis and feasibility for this novel concept. Becker et al. (4) successfully transferred the VGLN to the axilla and elbow in patients with upper limb lymphedema and showed promising long-term results. This physiologic lymph drainage procedure was transferred to the dependent wrist site with improved outcomes by Cheng’s group (5, 6).

INDICATIONS

The VGLN flap is indicated for postmastectomy upper limb lymphedema in patients who are not responsive to physical therapy with repeated episodes of cellulitis for 6 months, circumferential difference greater than 20%, or total occlusion on lymphoscintigraphy. It works by shunting the lymph from the surrounding interstitial tissue to the recipient vein (5, 7). Concerns regarding the donor site morbidity were reported (8, 9, 10). Theoretically, the risk of donor site lymphedema can be minimized by reverse mapping technique (11).

ANATOMY

The superficial groin lymph nodes can be divided into two distinct groups, which are supplied by the superficial circumferential iliac artery (SCIA) and a consistent medial branch that originates from the common femoral artery (CFA), 3 cm distal to the SCIA. The former has a pedicle length and diameter of 2.5 cm and 1.5 mm, and the latter 1.9 cm and 1 mm, respectively (6). The SCIA arises from anterolateral aspect of the CFA 2.5 cm inferior to the inguinal ligament. Shortly after its origin, the SCIA divides into superficial and deep branches. The superficial branch runs into the subcutaneous tissues 2 cm below and parallel to the inguinal ligament and provides vascular supply to the superficial inguinal lymph nodes. There is an average of 6 sizable superficial groin lymph nodes that can be harvested with a regular pedicle (6). Recently, an MRI study revealed that a mean of 8 superficial inguinal lymph nodes are confirmed below the inguinal ligament (12) (Figs. 126.1, 126.2, 126.3, 126.4).

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