Operative Technique in Plastic Surgery – Kevin C.Chung

44
CHAPTER
Amputation of the Lower
Extremity: Above-Knee
Amputation, Below-Knee
Amputation, Through-Knee
Amputation
Anahita Dua and Jason T. Lee
INTRODUCTION
■ Approximately 1.7 million Americans are living with the loss of a limb, and
this number is expected to nearly double by 2050.1
■ Amputations of the lower extremity may be performed for a myriad of reasons
including infection, trauma, cancer, and pain.
■ Thoughtful patient selection, early involvement of neuropsychiatry, and
physical medicine and rehabilitation (PM&R) are fundamental to a successful
outcome.
APPROACH CONSIDERATIONS
■ Before considering an amputation, the patient should be evaluated by vascular
surgery to ensure no other options (endovascular or open) exist.
■ Patients who are suited for an above-knee amputation (AKA) include those
who have limited or no mobility, a nonfunctional limb, infection that has
progressed above the knee, inadequate overlying skin/muscle to provide stump
coverage, and those patients who do not have adequate blood flow to heal a
below-knee amputation (BKA) incision (popliteal pressures less than 50 mm
Hg).
■ BKA is suited in patients who wish to ambulate with a prosthesis, do not have
extensive infection above the knee joint, and have popliteal pressures greater

than 50 mm Hg to heal the stump.
■ Knee disarticulations (through-knee amputations) represent less than 2% of all
amputations and are typically performed for trauma; they are best suited for
patients who are unlikely to ambulate.
■ AKA is also suitable for patients unlikely to ambulate, but cannot be
performed in patients with inadequate femoral artery blood flow as the AKA
stump will not heal.
■ Severe infection that involves the femoral head or proximal femur also
preclude AKA.2
PREOPERATIVE PLANNING
■ All patients undergoing an amputation should be evaluated early by both
neuropsychiatry and PM&R.
■ Thorough physical exam and arterial pressures should be used to determine
which level (AKA or BKA) is best for the patient (FIG 1).
■ Cardiac optimization is important given the high incidence of cardiac disease
among this patient population.
■ If discussing limb viability status post trauma, a multidisciplinary approach
involving vascular, orthopedic, and plastic surgery services should take place
prior to proceeding with amputation.

FIG 1 • Incisions for above-knee (AKA), below-knee
(BKA), and through-knee amputation.
T E C H N I Q U E S
■ Above-Knee Amputation
■ Place the patient supine with a small bump under the ipsilateral hip to
internally rotate the leg.
■ Outline the circumferential incision (fish mouth configuration)—amputation

level should be at the proximal femur, midfemur, or supracondylar.
■ Sharply dissect the skin, soft tissue, and muscle down to the femur.
■ Identify the vascular bundle and individually suture ligate the artery, vein,
and nerve—nerve should be transected as proximally as possible.
■ Using a periosteal elevator, elevate the femoral periosteum.
■ Transect the bone using a Gigli saw or battery-operated oscillating saw.
■ Bevel the femoral edge using the saw.
■ Utilize a rasp to smooth the bone edge.
■ Irrigate the wound thoroughly.
■ Complete the amputation with the amputation knife.
■ Approximate the anterior and posterior flaps with 0-Vicryl for deep fascia
and 2-0 Vicryl for superficial tissue using interrupted figure of eights.
■ Staple or suture the skin with 2-0 nylon.
■ Cover skin wound with antibiotic ointment, petroleum jelly dressing, and
cotton dressings for padding. Wrap a circumferential compressive elastic
dressing for the stump.
■ Below-Knee Amputation
■ Place the patient supine with a bump under the ipsilateral thigh and place a
thigh tourniquet.
■ Prep the lower extremity circumferentially up to the midthigh.
■ The anterior incision is placed 10 cm distal to the tibial tubercle (anterior
incision 2/3 total circumference), and the posterior incision (1/3 total
circumference) should be long enough to ensure flap coverage (typically 1.5
times the length of the anterior flap).
■ Carry down the anterior incision sharply to the tibia.
■ Carefully tie off the anterior tibial vessels with 2-0 silk suture.
■ Dissect through the lateral and superficial posterior compartments of the leg.
■ Using a periosteal elevator, remove the periosteum and soft tissue to expose
a clean segment of bone to be transected.
■ Using a Gigli saw or battery-operated saw, transect the tibia—bevel distal
tibia cut at 45 degrees.
■ Transect the fibula 2 cm proximal to the tibia.
■ Remove the muscle and soft tissue with an amputation knife.

■ In the posterior compartment, identify and ligate the peroneal and posterior
tibial vessels with 2-0 silk.
■ Tie all nerves with 2-0 silk and transect sharply as proximally as possible.
■ Utilize a rasp to smooth the edges of the tibia.
■ Deflate the tourniquet and coagulate or tie off any bleeding vessels.
■ Close pretibial fascia with 2-0 Vicryl figure of eights in an interrupted
fashion.
■ Staple or suture the skin.
■ Cover skin wound with antibiotic ointment, petroleum jelly dressing, and
cotton dressings for padding. Wrap a circumferential compressive elastic
dressing for the stump.
■ Through-Knee Amputation
■ Mark the leg at knee level with a posterior soft tissue flap of sufficient length
to close the incision without tension.
■ Proximal thigh tourniquet is placed, the patient is prepped and draped,
planned incisions are remarked, and the tourniquet is inflated without
exsanguination.
■ Incisions are created with sharp dissection and carried down
circumferentially to the level of the knee, through the joint, and along the
drawn posterior flap.
■ Distal leg is removed from the operative field.
■ Distal end of femur is shaved down from distal to proximal using a sagittal
saw anteriorly, posteriorly, medially, and laterally.
■ Do not manipulate the insertion of the adductor magnus muscle.
■ Preserve cruciate ligaments and posterior capsule.
■ Posterior articulating surface is shaved to cancellous bone.
■ Identify the patella and advance it to cover the distal surface of the femur.
■ Sew the quadriceps tendon to the cruciate ligament and posterior joint
capsule so that the posterior surface of the patella is in direct contact with the
distal end of the femur.
■ Sew the hamstring muscles to the quadriceps tendon and posterior capsule
using 2.0-polydioxanone (PDS) so the distal femur is covered.
■ Place a closed-suction drain, such as a Jackson Pratt (JP) drain over the

myodesis, and trim the posterior flap so it can be sewn to the anterior flap
using 2.0-Prolene vertical mattress suture.3
PEARLS AND PITFALLS
Posterior
flap
creation
■ Ensure that the flap length is adequate for coverage without being too
tight as a tight flap can result in necrosis of the closure.
Stump
edema
■ Swelling of the stump post operatively can result in wound healing
complications as it places tension on the suture line. Wrapping the
stump in a sterile ACE bandage for at least the first three days post
operatively will assist with keeping the edema to a minimum.
Knee
immobilizer
■ A knee immobilizer is a good adjunct to help keep the knee joint
straight during recovery. A straight and flexible knee joint is
imperative to being able to use a prosthesis for ambulation. A knee
immobilizer has to be used with caution as it can cause pressure
wounds to the knee area of the stump. It should be removed under
supervision daily during physical therapy to prevent pressure
wounds.
POSTOPERATIVE CARE
■ Keep the wound wrapped in sterile soft dressings and a pressure wrap for 3 to
5 days.
■ Staples/sutures will remain in place for a minimum of 4 weeks.
■ Drains may be removed when 24-hour output is less than 30 mL.
■ Ensure no contractures by placing a knee immobilizer in patients with a BKA.
■ Physical therapy and PM&R should be consulted early.
■ Nonweight bearing for 2 weeks.
■ Fit for prosthesis and advance rehabilitation in 3 to 6 months.4
REFERENCES
1. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the
prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med
Rehabil. 2008;89(3):422-429.

2. Morris CD, Potter BK, Athanasian EA, Lewis VO. Extremity amputations:
principles, techniques, and recent advances. Instr Course Lect. 2015;64:105-
117.
3. Albino FP, Seidel R, Brown BJ, et al. Through knee amputation: technique
modifications and surgical outcomes. Arch Plast Surg. 2014;41(5):562-570.
4. Perkins ZB, De’Ath HD, Sharp G, Tai NR. Factors affecting outcome after
traumatic limb amputation. Br J Surg. 2012;99(suppl 1):75-86.

45
CHAPTER
Section VI: Lymphedema
Lymphaticovenous
Anastomosis
Ann-Charlott Docherty Skogh and Martin Halle
DEFINITION
■ Lower extremity lymphedema can either be primary, occurring as a structural
or anatomical birth defect, or secondary following surgery and/or radiotherapy,
trauma, infection, and other causes.
■ Chronic lymphedema is a progressive condition where tissue remodeling lead
to fibrosis and fat deposition if not treated adequately.
■ Lymphedema can be severely disabling and affect the patient’s daily life with
difficulties in range of motion, fitting into normal clothing, and can also cause
psychological distress.
ANATOMY
■ The lymphatic system is composed of collecting vessels and lymph nodes.
■ The lymphatic system of the lower extremities includes a superficial and a
deep system divided by the muscle fascia-aponeurosis. Perforating lymphatic
vessels interconnect both systems.
■ The superficial system includes the interfascial and epifascial subsystems,
where the latter is the most superficial one, located between the skin and the
saphenous fascia (FIG 1).

FIG 1 • A. The lymphatic vessels of the lower limb drain
into the inguinal and pelvic system and proximally to
cisterna chyli. B. The sub- and intradermal lymph
capillaries drain into deeper lymphatic collectors located
below the dermis.
PATHOGENESIS
■ Lymphedema can be primary, occurring as a structural or anatomical birth
defect in which genetics seem to play a major role. Secondary lymphedema
may occur after surgery and/or radiotherapy, trauma, infection, and other
causes. Lymphatic filariasis following infection of invading pathogens is
globally the most common cause of secondary lymphedema.1
■ The transport capacity of lymphatic drainage may be reduced by damage that
further affects the homeostasis of the interstitium, including both the cellular
and extracellular compartments.

■ Lymphostasis with fluid accumulation in the tissues leads to inflammation and
subsequent tissue remodeling of skin and subcutaneous tissues with fibrosis
and fat deposition.
NATURAL HISTORY
■ Untreated lymphedema tends to deteriorate with time, leading to fibrosis and
fat deposition that occur at later stages. Inflammatory changes make the patient
susceptible to recurrent episodes of erysipelas and cellulitis.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Initially, there is a phase with reduced transport capacity without clinical
swelling.
■ Stage 1 lymphedema includes pitting edema that subsides with limb elevation,
whereas elevation is not effective in stage 2, when fibrosis of the tissues may
already be seen.
■ Stage 3 includes increasing volume of the extremity with congestive
dermatitis, trophic skin, and fat deposition.2
■ A pitting test shall be performed with pressure applied to the affected area
(ideally over the tibial bone) for at least 60 seconds with the examiners fingers.
The absence of pitting confirms tissue remodeling and fat deposition, where
lymphaticovenular anastomoses may be less successful and suction-assisted
lipectomy shall be considered.3
IMAGING
■ Imaging methods for lymphedema include radionuclide lymphoscintigraphy,
indocyanine green (ICG) lymphography, and magnetic resonance
lymphangiography.
■ Lymphoscintigraphy can indicate the location of lymph collectors, but does
not provide information about specific areas of occlusion.2
■ ICG lymphography, on the other hand, visualizes real-time superficial lymph
flow without radiation exposure.4

Video p7-c045
■ ICG lymphographic patterns are categorized from normal linear pattern (stage
0) to abnormal dermal backflow patterns; splash (stage I), stardust (stages II–
IV), and diffuse stardust (stage V) patterns with lymphedema progression of
the lower extremity5 (FIG 2).
DIFFERENTIAL DIAGNOSIS
■ Venous insufficiency
■ Deep vein thrombosis
■ Thrombophlebitis
■ Erysipelas
■ Renal failure
■ Cardiac failure
■ Neurofibromatosis
■ Lymphangioma
■ Others
00:00 / 00:00

FIG 2 • A. Right leg lymphedema. B,C. ICG images
illustrating different flow patterns. Linear pattern (D),
stardust pattern (E), and diffuse pattern as described by
Narushima M, Yamamoto T, Ogata F, et al.
NONOPERATIVE MANAGEMENT
■ Decongestive physiotherapy and compression garments have been the most
common nonsurgical treatment methods in reducing edema volumes, although
they are not curative.
SURGICAL MANAGEMENT
■ Surgical treatment of lymphedema includes debulking surgery, suction-
assisted lipectomy, vascularized lymph node transfer, and lymphaticovenular,
lymphaticovenous, and lymphatico-lymphatic anastomosis.6
■ Suction-assisted lipectomy is usually performed for late lymphedema, when
edematous tissues has remodeled to adipose tissue, without remaining signs of
pitting edema. However, there is still a lack of consensus whether vascularized
lymph node transfer or lymphaticovenous anastomosis is the primary choice in
pitting lymphedema.
■ Surgical treatment of lymphedema with lymphaticovenular anastomosis has
recently gained popularity due to better imaging systems together with recent
technical advances in supramicrosurgery, including high magnification

operative microscopes and supramicrosurgical instruments.7,8
Preoperative Planning
■ Positive pitting test is of paramount importance for the prognosis, because the
absence of pitting may reveal a certain degree of irreversibility of the
lymphedema.
■ Lymphoscintigraphy facilitates confirmation of the diagnosis.
■ ICG lymphography is commonly performed using a photodynamic eye (PDE)
camera (Hamamatsu Photonics, K.K, Hamamatsu, Japan), ideally in an
outpatient setting for patient selection and subsequently repeated
perioperatively.
■ Preoperative markings of linear flow as well as dermal backflow areas, based
on ICG imaging, facilitate selection of anatomical sites for multiple LVAs.
Positioning
■ The patient is usually positioned supine or in a unilateral “frog-leg” position
for better access to medial structures, depending on results from preoperative
ICG imaging.
Approach
■ The procedure may be performed under local anesthesia, whereas general
anesthesia is recommended if any movement during surgery is to be avoided.
■ The use of two or three microscopes can facilitate the performance of multiple
anastomoses.
T E C H N I Q U E S
■ Lymphaticovenous Anastomosis
■ A volume of 0.3 to 1.0 mL ICG (Pulsion Medical Systems SE, Feldkirchen,
Germany, 5 mg/mL) is injected intradermally into the first web space of the
affected leg to locate lymphatic vessels suitable for anastomosis (TECH FIG
1A,B). Similarly, the technique can be used for upper extremity
lymphedema, performed with intradermal injection into the first and fourth
web space.
■ A linear flow pattern segment confirmed by ICG lymphangiography is

chosen (TECH FIG 1C,D).
■ A 15- to 30-mm incision transverse to the selected lymph vessel is
performed into the deep layer of dermis. The remaining thickness of the
dermis is gently dissected under meticulous hemostasis, avoiding injury to
the subdermal lymphatic vessels and venules (TECH FIG 1E).
■ If lymphatic vessels are difficult to locate, a complementary injection of 0.3-
to 1.0-mL patent blue (Patentblau, Guerbet, Germany V, 25 mg/mL) can be
administered intradermally, a few centimeters distal to the skin incision.
■ Suitable subdermal venules (around 0.5 mm in diameter) are explored
adjacent to the chosen lymphatic vessel (TECH FIG 1F).
■ Preparation and alignment of vessels (TECH FIG 1G,H).
■ A stent using 6-0 nylon suture that is placed into the lumen of the vessels
may be used to facilitate anastomosis of the vessels, which range from 0.3 to
0.8 mm (TECH FIG 1I,J).
■ Patent blue or ICG lymphography can be used to confirm patency of LVA
(TECH FIG 1K).
■ The venules of choice may differ in diameter compared to the lymphatic
vessels, where different types of anastomoses may be applied. The first
choice is an end-to-end anastomosis. If a Y-shaped venule is available, both
afferent and efferent lymphatic flow can be diverted into the same venule9
(TECH FIG 1L–P).
TECH FIG 1 • A. Injection of indocyanine green into
the first web space of the foot. B. ICG staining of
lymphatic vessels in the foot as seen with PDE
camera. C. Markings on the skin of the leg after
injection of ICG. D. ICG staining of linear lymphatic
vessels in the leg as seen with PDE camera. E.

Incision of the skin showing subdermal venule (V) and
lymphatic vessel (L). F. Preparation of venule (V) and
lymphatic vessel (L) stained with patent blue. G.
Preparation of venule (V) and lymphatic vessel (L)
stained with patent blue with background to facilitate
anastomosis. H. Aligning of vessels before suturing. I.
Stent using 6-0 nylon suture to prevent back wall
stitches. J. End-to-end lymphaticovenular
anastomosis with 12-0 nylon sutures. Vessels with
luminal diameter of approximately 0.5 mm. K.
Lymphatic flow over anastomosis as shown by patent
blue staining in lymphatic vessel and venule. L.
Different types of lymphaticovenous anastomoses
according to Narushima et al.9 (V) Venule or vein, (L)
lymphatic vessel. M. Preparation of Y-shaped vein and
lymphatic vessel. N,O. Coaptation of vein and
lymphatic vessel with antegrade and (P) retrograde
flow.

G H

PEARLS AND PITFALLS
■ Choose small venules to avoid venous backflow.
■ Tension-free anastomosis is of great importance due to the low-flow nature of
lymphatic vessels and venules.
■ Perioperative antibiotics are indicated due to long surgery time and an increased risk
for erysipelas in lymphedema patients.
■ The dorsum of the foot and lower leg are usually good locations to perform LVAs in
the lower extremity. The lymphatic vessels are usually easy to find after examination
with ICG, complemented with patent blue if necessary. The upper extremity presents
a similar pattern, where it is easier to find suitable vessels on the dorsum of the hand
and in the forearm compared to the upper arm.
■ LVAs may be more difficult to perform in the thigh area due to the greater width of
the epifascial compartment.

POSTOPERATIVE CARE
■ Low molecular weight heparin is indicated the first postoperative week due to
immobilization during surgery.
■ Postoperatively, the leg is kept slightly elevated at night and a low-pressure
bandage is applied the day after surgery to avoid interstitial swelling.
■ Postop day 1, the patient is allowed to ambulate with full weight bearing with
a low-pressure bandage applied (about 30 mm Hg), but with reduced physical
activity.
■ Normal physical activity can be resumed after 3 weeks.
OUTCOMES
■ Several case reports of successful treatment of lower extremity lymphedema
with LVAs are available, and multiple LVAs seem to be favorable.10
■ Reduced number of episodes of erysipelas after LVAs has been reported.11
■ The outcome of lower extremity LVAs has been less investigated as compared
to upper extremity LVAs, and data from prospective, controlled studies are
scarce.
COMPLICATIONS
■ Infections may occur in the postoperative period and shall be treated with
antibiotics.
■ Temporary local redness can occur due to venous backflow into the
anastomosis.
■ Deterioration of the lymphedema is a very rare complication, but can occur,
after LVA surgery.
REFERENCES
1. Olszewski WL. The pathophysiology of lymphedema—2012. Handchir
Mikrochir Plast Chir. 2012;44:322-328.
2. Murdaca G, Cagnati P, Gulli R, et al. Current views on diagnostic approach
and treatment of lymphedema. Am J Med. 2012;125:134-140.
3. Brorson H, Ohlin K, Olsson G, et al. Controlled compression and liposuction
treatment for lower extremity lymphedema. Lymphology. 2008;41(2):52-63.
4. Ogata F, Narushima M, Mihara M, et al. Intraoperative lymphography using
indocyanine green dye for near-infrared fluorescence labeling in lymphedema.
Ann Plast Surg. 2007;59(2):180-184.
5. Narushima M, Yamamoto T, Ogata F, et al. Indocyanine green lymphography

findings in limb lymphedema. J Reconstr Microsurg. 2016;32(1):72-79.
6. Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of current
surgical treatments for lymphedema. Ann Surg Oncol. 2014;21(4):1195-1201.
7. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical
lymphaticovenular anastomosis for the treatment of lymphedema in the upper
extremities. J Reconstr Microsurg. 2000;16(6):437-442.
8. Koshima I, Nanba Y, Tsutsui T, et al. Long-term follow-up after
lymphaticovenular anastomosis for lymphedema in the leg. J Reconstr
Microsurg. 2003;19(4):209-215.
9. Narushima M, Mihara M, Yamamoto Y, et al. The intravascular stenting
method for treatment of extremity lymphedema with multiconfiguration
lymphaticovenous anastomoses. Plast Reconstr Surg. 2010;125(3):935-943.
10. Maegawa J, Hosono M, Tomoeda H, et al. Net effect of lymphaticovenous
anastomosis on volume reduction of peripheral lymphoedema after complex
decongestive physiotherapy. Eur J Vasc Endovasc Surg. 2012;43(5):602-608.
11. Mihara M, Hara H, Furniss D, et al. Lymphaticovenular anastomosis to
prevent cellulitis associated with lymphoedema. Br J Surg.
2014;101(11):1391-1396.

46
CHAPTER
Lymphedema: Lymph Node
Transfer
Adrian S. H. Ooi and David W. Chang
DEFINITION
■ The lymphatic system is responsible for reabsorption of excess interstitial
fluid, protein, and waste products, as well as filtration and removal of foreign
material from interstitial fluid and absorption of lipids from intestines. Up to
50% of the body’s circulating albumin is processed through the lymphatic
system every day.
■ Lymphedema is an abnormal accumulation of protein-rich fluid in the
interstitial compartment resulting in edema formation.
■ It occurs when the generalized or regional lymphatic load exceeds its transport
capacity.
■ Long-standing lymphedema leads to chronic inflammation, adipose tissue
hypertrophy and fibrosis, and eventually lymphatic channel fibrosis.
■ Lymphedema is a problem that affects about 200 million people worldwide.
■ Distribution: Lower limb 90% greater than upper limb 10% greater than
genitalia 1%.
ANATOMY
■ Endothelial cells bud off from veins during early embryonic development and
transdifferentiate to form the lymphatic vasculature.
■ The lymphatic primary plexus is composed of capillary-like vessels and is
further remodeled to form pre-collecting, collecting, and ductal components.
The major lymphatic ducts are formed by two paired lymph sacs (jugular and
iliac) and two unpaired sacs (retroperitoneal and cisterna chyli).
■ Lymphatic channels are thin-walled vessels composed of endothelial cells
connected by discontinuous junctions and surrounded by smooth muscle. The

basement membranes of the larger, deeper lymphatic vessels have multiple
intercellular gaps, which form valves through which fluid flows
unidirectionally.
■ The superficial dermal lymphatics are unvalved and drain into the valved
subfascial deep dermal system, which run with the superficial veins.
■ Lymphatic fluid is then transported through afferent lymphatic channels to
lymph nodes, which are gathered in basins throughout the body. After
undergoing immunological processes within the lymph nodes, the fluid flows
out through efferent lymphatic channels and ultimately into the thoracic ducts
and subclavian veins where they rejoin the venous circulation.
■ Lymph nodes are bean-shaped structures distributed along the lymphatic
channels. They consist of a capsule, an outer cortex and an inner medulla.
Multiple afferent lymphatics can enter via the outer cortex, and a lymph node is
supplied by an artery and a vein at the hilar region, which accompany a single
efferent lymphatic vessel. The lymph nodes contain lymphocytes and
macrophages, which are responsible for removal of organisms, foreign
substances, and tumor cells.
■ Lymph nodes are distributed deep in the body along the respiratory and
gastrointestinal tract and superficial in the cervical, thoracic, and inguinal
regions.
■ Lymphatic fluid transportation is under humoral influences and is propelled by
a combination of:
■ Smooth muscle surrounding the collecting vessels that have an intrinsic
autocontractile mechanism
■ Extrinsic compression by neighboring skeletal muscles
■ Negative intrathoracic pressure
PATHOGENESIS
■ Lymphatic homeostasis is a function of filtration of plasma across the capillary
walls into the interstitial compartment and absorption by the lymphatic system.
This rate of filtration is governed by the Starling equation whereby net
filtration is determined by intra- and extracapillary hydrostatic and oncotic
forces.
■ Lymphedema arises when the rate of filtration exceeds absorption by 2 to 4
L/d.
■ This disruption can occur at the level of the lymphatic vasculature or the
lymph nodes and can arise due to a primary or secondary disease process.

■ True primary lymphedema can be classified as congenital (Milroy disease),
pubertal/praecox (Meige disease), and tarda, which occurs in the adult age
group. Lymphedema praecox is the most common form of primary
lymphedema.
■ Lymphedema can also arise secondary to acquired damage to the lymphatic
system. These include infection, trauma, malignancy, surgery, and radiation.
■ The most common cause worldwide is filariasis, caused by the parasite
Wuchereria bancrofti. In the developed world, it is most commonly due to
treatment for cancer.
■ For breast cancer treatment, it occurs in up to 40% of cases with lymph node
dissection and radiation and 5% of cases with sentinel lymph node biopsy.
■ 41% after gynecological cancer treatment.
■ 12% to 55% after groin lymph node dissection.
NATURAL HISTORY
■ When there is disruption in the lymphatic system and as lymphatic pressure
builds, flow within the lymph vessels stagnates, leading to valvular
incompetence and dermal backflow.
■ Lymphedema is confined to the subcutaneous compartment as the deeper
lymphatics are driven by the skeletal muscle pump.
■ Over time, macromolecular protein and hyaluronan are deposited in the
interstitium leading to increased tissue colloid osmotic pressure.
■ Fibroblast, monocytes, adipocytes, and keratinocytes also increase within the
tissue, leading to increased collagen deposition, degeneration of elastic fibers,
and fibrovascular proliferation.
■ The basement membranes of lymphatic vessels are obliterated and the vessels
become fibrotic.
■ This combination results in nonpitting edema, and eventually a chronic
inflammatory state ensues.
■ The cytokines arising from the inflammation and the disruption in lymphatic
flow of lipids leads to adipose deposition and hypertrophy in the interstitium.
■ The verrucous appearance of long-standing lymphatic extremities is caused by
hyperplasia of skin at the dermal-epidermal junction.
■ Lymphatic stasis and decreased immunological function predispose the patient
to an increased risk of local skin infections, erysipelas, and later, lymphangitis.
The excess tissue can lead to symptoms of pain, heaviness, and decreased
mobility. Long-standing chronic lymphedema can lead to development of

lymphangiosarcoma (Stewart-Treves syndrome). Lymphedema has significant
adverse impact on patients’ quality of life and psychosocial health.
■ The International Society of Lymphangology (ISL) has classified lymphedema
into three stages:
■ 0: Latent/subclinical period
■ I: Pitting edema which is reversible on elevation
■ II: Tissue fibrosis and edema, which is nonreversible on elevation
■ III: Elephantiasis and trophic skin changes
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The history is targeted at determining the diagnosis and etiology of
lymphedema, duration, symptoms, and complications, and how the patient has
been managing it.
■ Elucidating diagnosis and etiology include asking about risk factors for
malignancy, travel history, prior surgical procedures, history of radiation
therapy, trauma and infection, and family history. Obesity can contribute to
lymphedema through the overload of lipids in the body. Other causes of
extremity swelling such as congestive cardiac failure, venous insufficiency,
and deep vein thrombosis have to be excluded (see differential diagnosis).
■ Important symptoms and complications to ask about include pain and
infections in the affected extremity, a feeling of heaviness and difficulty in
movement.
■ The examination of the patient with lymphedema should include a general
physical and a targeted examination of the affected part. The general
examination is aimed at excluding any active infection or malignancy and
general causes of extremity edema.
■ Lymphedema is typically unilateral, with the swelling beginning distally and
progressing over months to years.
■ The edema starts off soft and pitting and eventually becomes nonpitting as
interstitial fibrosis sets in.
■ There is minimal pigment change or ulceration and peau d’orange indicating
dermal fibrosis can be present.
■ Late changes in the extremity include hyperkeratosis, papillomatosis, and the
development of a positive Stemmer sign in which the skin on the dorsum of
the second web space of the foot cannot be pinched as a fold.
■ Reproducible measurements of the limb should be taken to help with accurate
follow-up. These can include circumference measurements and volumetric

measurements such as water displacement tests, perometry, and bioimpedance
testing. Digital photographs are also useful for comparative analysis.
■ Circumference measurements are typically taken at 4- to 10-cm intervals
from consistent landmarks such as the patella in the lower extremity and the
olecranon in the upper extremity. Figures that are used in the diagnosis of
lymphedema include the following:
• Greater than 2 cm difference from the nonaffected limb.
• Severity can be graded as mild (greater than 10% difference), moderate
(greater than 20%), and severe (greater than 30%).
■ Water displacement has been the standard for volume measurement and is
highly accurate but cumbersome. Lymphedema is diagnosed if the volume
differential of the affected limb is greater than 10% of the normal limb.
■ Perometry utilizes an infrared optical electronic scanner to calculate volume.
■ Bioimpedance testing calculates the fluid composition of an affected limb
using resistance to an electrical current.
IMAGING
■ Lymphangiography is the visualization of lymphatic vessels using contrast
medium. Vessels can be classified as anaplastic, hypoplastic, or hyperplastic.
There are the direct and indirect forms of lymphangiography.
■ Direct lymphangiography involves transecting distal lymphatic vessels and
directly injecting water-soluble iodide contrast medium into them. This has
largely been abandoned because of patient discomfort and damage to the
lymphatic channels.
■ Indirect lymphangiography injects contrast medium distally into the
subepidermis and uses radiographic imaging to delineate the lymphatic
system.
■ Isotopic lymphoscintigraphy is the current standard for lymphatic imaging. It
injects Technetium-99–labeled albumin into the subepidermis of the distal
affected extremity and timed post injection imaging to determine lymphatic
anatomy and function. It has a sensitivity of 97% and specificity of 100%.
However, when done awake, the injection can be painful, and the length of
time required can be distressing to the patient.
■ The injection of indocyanine green (ICG) and imaging using an infrared
camera have become widely used in the imaging of lymphatic vessels and are
particularly useful intra-op when needing to delineate the superficial lymphatic
system. A classification based on the appearance of the ICG has been

developed and correlated with the Campisi classification (Table 1).1
■ Computed tomography (CT) and magnetic resonance imaging (MRI) scanning
are useful in determining the architecture of the affected limb and elucidating
any underlying cause such as neoplasm. There is commonly a “honeycomb”
appearance above the deep subcutaneous fascia. MRI with contrast has proven
promising in outlining lymphatic vasculature.2
Table 1 Indocyanine Green Appearance to Classify Severity of
Lymphedema
Stage
Description
0
No dermal backflow
I
Splash pattern around the axilla/groin region
II
Stardust pattern proximal to the patella/elbow
III
Stardust pattern distal to the patella/elbow
IV
Stardust pattern in the entire limb
V
Diffuse pattern
DIFFERENTIAL DIAGNOSIS
■ Venous insufficiency
■ Deep venous thrombosis
■ Vascular malformations
■ Lipedema
■ Myxedema
■ Fluid overload
■ Congestive cardiac failure
■ Renal failure
■ Liver failure
■ Hypoalbuminemia
■ Soft tissue tumors
■ Morbid Obesity
NONOPERATIVE MANAGEMENT
■ Nonoperative management is aimed at reducing the amount of swelling and
treating any resulting complications. The former is accomplished by

compression and massage therapy, whereas the latter involves adequate skin
care and early detection of infection and treatment with the appropriate
antibiotics. In a compliant patient, this helps to slow down the progress of
lymphedema.
■ Patients should be educated about lymphedema and its complications, and
given responsibility for their own care.
■ Conservative treatment of lymphedema has been well researched and the
regimen described is complete decongestive therapy (CDT). This should be
started early to have the most benefit and is useful in cases of lesser than stage
III lymphedema. Analyses have shown up to 40% to 60% reduction in
lymphedema volume. It consists of two phases:
■ Initial reductive phase (up to 8 weeks) consisting of:
• Manual lymphatic drainage—Circular tissue stretching massage with
varying degrees of pressure
• Compression therapy during waking hours
• Regular skin care
• Targeted exercise
■ Maintenance phase consisting of
• Self-conducted lymphatic drainage
• Continuation of compression garments
■ Weight loss may help with lymphedema by reducing the flow of fatty acids
through lymphatic channels and decreasing fatty deposition in the
subcutaneous tissue.
■ Exercises such as swimming can be useful in reducing the severity of
lymphedema.
■ Unsubstantiated nonoperative measures include coumarin (5,6 benzo-a-
pyrone), diuretic use, microwave heating, and intra-arterial injection of
lymphocytes.
SURGICAL MANAGEMENT
■ Although significant advances have been made in the surgical treatment of
lymphedema, no surgical technique offers a cure, and an aggressive trial of
nonsurgical therapy should first be done.
■ Indications for surgical treatment include failed conservative therapy, grossly
impaired limb function, debilitating extremity size and weight, recurrent
lymphangitis (greater than 3 episodes of infection per year), and uncontrolled

pain.
■ Surgical techniques for the treatment of lymphedema are classified as
excisional and physiological.
■ Excisional techniques aim to reduce the amount of lymphatic tissue and
tighten the skin envelope. They are described elsewhere in this book and
include but are not limited to excision and skin grafting (eg, Charles
procedure), staged excision, liposuction, and, more recently, radical resection
with preservation of perforators (RRPP).3 Unfortunately, as the primary disease
process is not addressed, there is a high risk of recurrence with these
techniques, and the appearance can be undesirable.
■ Physiological techniques attempt to replicate the normal lymphatic flow in the
affected extremity. Procedures that have been developed and described
elsewhere include buried dermal flaps, lymphovenolymphatic bypass,
lymphatic bypass, and lymphovenous anastomosis (LVA).4
■ The vascularized lymph node transfer (VLNT) is a physiological technique
that transfers intact autologous lymph nodes from a nonlymphedematous
region of the body to the affected extremity. In a sense, this is the most
physiological method of addressing the problem in a patient whose
lymphedema is due to damage to or paucity of lymph nodes in a particular
basin.
■ The lymph nodes are microsurgically anastomosed to the chosen recipient site
vessels and allowed to develop collateral blood supply. Over time, reported
mechanisms of lymphedema reduction include reduction of scarring at the
recipient site, hydrostatic “pumping” of intraflap lymph via arterial inflow and
venous outflow, and lymphangiogenesis aided by the production of VEGF-C
by the transplanted lymph nodes.
■ Though not curative, physiological techniques have proven to alleviate
symptoms and reduce lymphedema volume.
Preoperative Planning
■ Preoperative workup should include elucidating etiology of the lymphedema,
comorbidities, the patient’s treatment to date, limb measurements, weight
fluctuations, and ability to comply with therapy.
■ Severity of lymphedema should be clinically staged according to the ISL
grading system, and treatment planned accordingly:
■ Patients with mild to moderate stage 1 or 2 lymphedema are best candidates

for physiologic procedures such as VLNT and/or LVA.
■ Patients with stage 3 fibrofatty lymphedema or elephantiasis may benefit
from excisional procedures prior to physiologic procedures in order to offset
the lymphatic load and optimize the result of physiologic procedures.
■ Specific history to note with regard to vascularized lymph node (VLN) harvest
includes previous surgery in the region of planned harvest or pre-existing
lymphedema if harvest is planned from the groin. Scars and surface anatomical
landmarks should be noted. Active infection in the affected extremity should be
ruled out.
■ Definitive diagnosis of lymphedema is made with lymphoscintigraphy, which
evaluates lymphatic function.
■ ICG imaging of the affected extremity prior to surgery aids in lymphatic
mapping for the simultaneous performance of LVA.
■ If groin VLNT is planned, reverse lymphatic mapping should be performed to
determine the crucial deep groin lymph node basin of the lower extremity,
which should be avoided in groin VLNT harvest.
■ This involves the preoperative injection of technitium-99–labeled albumin
subcutaneously into the inner thigh and a gamma probe used intraoperatively
to detect the sentinel lymph node of the deep groin lymph node basin.5
■ Harvest of this lymph node should be avoided at all costs to prevent
postoperative lower extremity lymphedema.
Positioning
■ For most VLN harvest, the patient is placed in a supine position.
■ For TAP flap or split LD flap with LNT, the patient is placed in lateral
decubitus position.
■ If the lymph nodes are intended to be placed in the axilla, the arm is extended
at right angles to the torso to access and prepare the recipient site.
■ For specific points for each source of VLN, refer to the subheadings below.
Table 2 Comparison of Different Vascularized Lymph Node Transfer Donor
Sites
Donor site
Average
Number
of Lymph
Nodes
Advantages
Disadvantages

Supraclavicular
2–3
• Inconspicuous donor
site
• Low risk of causing
donor site
lymphedema
• Variable anatomy
• Need for meticulous
harvest technique
Submental
3–4
• Consistent anatomy
• Low risk of causing
donor site
lymphedema
• Visible donor site scar
• Risk of injury to the
marginal mandibular
nerve
Thoracic
Variable
• Ability to harvest with
latissimus dorsi or
thoracodorsal artery
perforator flap
• Inconspicuous donor
site scar
• Risk of upper
extremity lymphedema
Inguinal
5–8
• Ability to harvest with
abdominally based flap
• Inconspicuous donor
site
• Risk of lower extremity
lymphedema
Omentum
Unknown
• No risk of causing
donor site
lymphedema
• If harvested
laparoscopically,
minimal donor site scar
• Need to enter
abdominal cavity
• No skin paddle
possible
Approach
■ For harvest of VLN, the common sources are the submental, supraclavicular,
thoracic, inguinal, and omental lymph nodes. The advantages, disadvantages,
and potential complications of each are listed in Table 2.
■ For recipient sites in the limbs, placement location and the need for a skin
paddle for the VLNT are debated.
■ Some surgeons prefer proximal placement of the lymph nodes, whereas
others prefer distal placement. This is dependent on which mechanism the
lymph nodes are thought to work.
• For the “pumping” mechanism, distal sites such as the ankle and wrist are

chosen as gravitational forces aid in the flow of lymphatics.
• For the argument that VLNT works by promoting lymphangiogenesis, more
proximal sites near the vicinity of lymph node damage are chosen. It is
thought that dual effect of scar release and placement of well-vascularized
lymph nodes enhance the restoration of lymphatic flow.
■ It is likely that both mechanisms contribute simultaneously to the resolution
of lymphedema. A conservative approach to recipient site selection is
therefore the best approach.6
■ The proximal site is chosen when there is a definite area of scarring from
previous surgery or radiation.
• When it is difficult to access or remove scars, the VLNT can be done distal
to the site of obstruction. An example is in patients whose pelvic lymph
nodes were removed via intra-abdominal surgery.
• In patients who have no definite site of injury, placement of the VLNs
directly proximal to the area of the swelling is effective.
■ VLNT should be monitored if possible in most cases as in any other free
tissue transfers. A skin paddle can be helpful when closure of native skin
over the lymph nodes is tight, such as at the wrist, but is not cosmetically
appealing. This can be resolved by excision of the skin paddle at a second
stage.
■ Our preference is to harvest supraclavicular lymph nodes without a skin
paddle, and place them at the axilla for the upper extremity and the groin for
the lower extremity.
■ We use an implantable Doppler probe postoperatively to monitor the
microanastomotic patency.
T E C H N I Q U E S
■ Supraclavicular Vascularized Lymph Node
Harvest
■ Based on the transverse cervical (TC) artery.
■ The flap can be harvested with or without a skin paddle.
■ Surface landmarks (TECH FIG 1A) are a triangle formed by the clavicle
(inferior border), lateral edge of the sternocleidomastoid muscle (SCM;

medial border), and external jugular vein (lateral border).
■ Lymph node harvest from the right neck is preferable to avoid the risk of
damaging the thoracic duct in the left side of the neck. Lymph nodes are
harvested from the left neck if the lymphedema involves right arm.
■ In the supine position, the patient’s head is tilted 45 degrees away from the
side of harvest.
■ A longitudinal skin incision is made 1 to 2 cm above the superior border of
the clavicle between the medial and lateral borders (TECH FIG 1B).
■ If harvesting a skin paddle, the perforator to the skin should be marked
with a Doppler probe prior to harvest and an ellipse marked encompassing
the perforator along the line of the recommended skin incision.
■ The platysma is breached with sharp dissection, and the omohyoid muscle or
tendon is identified and cut to reveal fat and lymphatic tissue posteriorly
(TECH FIG 1C).
■ Medial dissection proceeds along the lateral border of the SCM. The internal
jugular vein (IJV) is next identified, and the tissue within the triangle gently
dissected off. The anterior scalene muscles are identified at the base.
■ Proceeding inferiorly from the medial border, the TC artery can usually be
identified arising from the thyrocervical trunk (TECH FIG 1D).
■ Pedicle length should be maximized by dissecting down to the source
vessel.
■ There is usually an accompanying vein supplying the flap arising from the
IJV or subclavian vein.
■ The distal ends of the TC vessels are identified and ligated.
■ Using the EJV as the lateral landmark, lateral dissection then proceeds in a
natural plane medial to the trapezius muscle and stops once the anterior
scalene muscles are identified at the base.
■ Once the borders have been dissected, the supraclavicular VLN flap can be
lifted off the anterior scalene muscles and the flap isolated on its vascular
pedicle (TECH FIG 1E).
■ The phrenic nerve should be identified and preserved.
■ When the recipient site is ready, the pedicle can be ligated.
■ Donor site closure is done over a suction drain placed away from the IJV.
The platysma is approximated with interrupted absorbable polyfilament
sutures, and the skin is closed with a running subcuticular suture.

TECH FIG 1 • A. Surface marking of supraclavicular
lymph node transfer. B. A ongitudinal skin incision is
made 1 to 2 cm above the superior border of the
clavicle between the medial and lateral borders. C.
The platysma is split with sharp dissection, and the
omohyoid muscle or tendon is identified and cut to
reveal fat and lymphatic tissue posteriorly. D.
Proceeding inferiorly from the medial border, the
thoracodorsal (TD) artery can usually be identified
arising from the thyrocervical trunk. E. Once the
borders have been dissected the supraclavicular VLN
flap can be lifted off the anterior scalene muscles and
the flap isolated on its vascular pedicle. (From Ooi AS,
Chang DW. 5-step harvest of supraclavicular lymph

nodes as vascularized free tissue transfer for
treatment of lymphedema. J Surg Oncol. 2017;115:63-
67.)
■ Submental Vascularized Lymph Node Harvest
■ Based on the facial artery and its submental branch.
■ The flap can be harvested with or without a skin paddle.
■ Surface landmarks are the symphysis, body and angle of the mandible, and
facial artery.
■ The facial artery is palpated and marked as it crosses the inferior border of
the mandible. The skin incision is made 1 cm posterior to the lower border of
the mandible.
■ If a skin paddle is desired, a handheld Doppler probe is used to detect the
perforators from the submental artery (SMA). An ellipse encompassing the
perforators is designed extending from the symphysis medially to the angle
of the mandible laterally, with the upper margin along the lower border of
the mandible from the mandible angle to the symphysis. The initial skin
incision is then initiated at the upper margin of the ellipse.7
■ The incision is deepened through the platysma, and the SMA is identified
at its junction with the FA. The marginal mandibular branch of the facial
nerve is identified as it crosses the FA and must be preserved. The SMA is
dissected proximal to distal end along its axis.
■ The submental lymph nodes are found at the junction of the SMA and FA,
and the soft tissue at this region is included to preserve the maximal amount
of lymphatic tissue.
■ If a skin paddle is included, the septocutaneous perforator from the SMA to
the skin paddle must be preserved. To aid with this, the anterior belly of the
digastric muscle can be included with the perforator.
■ The distal ends of the facial vessels are ligated, and the submental lymph
nodes are harvested with the submental vessels and the proximal facial
vessels to maximize pedicle length.
■ The donor site is closed primarily over a suction drain. The platysma is
approximated with interrupted absorbable polyfilament sutures, and the skin
is closed with a running subcuticular suture.

■ Thoracic Vascularized Lymph Node Harvest
■ Based on the thoracodorsal (TD) vessels or the lateral thoracic (LT) vessels:
■ The thoracic lymph nodes can be harvested as part of a muscle-sparing
latissimus dorsi (LD) or thoracodorsal artery perforator (TAP) flap, which
can be used for simultaneous pedicled breast reconstruction.
■ A longitudinal line just anterior to the LD muscle and lateral to the breast is
marked and incised (TECH FIG 2A).
■ The TD pedicle is located as it enters the LD muscle, and the LT vessels can
be identified just anterior to this as it hugs the serratus anterior muscle fascia.
■ The lymph nodes to be harvested are located inferior to the lateral border of
the pectoralis minor muscle (TECH FIG 2B). These are the level 1 lymph
nodes of the axillary region, and harvest of these will avoid damage to the
draining lymphatics of the arm.
■ If the lymph nodes alone are harvested, the LT pedicle is preferred as they
are the preferential supply.8
■ If a pedicled LD or TAP flap is desired for breast reconstruction, the lymph
nodes are captured as an anterior extension of the flap skin paddle. As the
flap is transposed into the breast anteriorly the lymph nodes are swung
upward and placed in the axilla (TECH FIG 2C).
■ The donor site is closed primarily over a suction drain. The superficial fascia
is approximated with strong absorbable polyfilament sutures, and the skin is
closed with a running subcuticular suture.
TECH FIG 2 • A. A longitudinal line just anterior to the
LD muscle and lateral to the breast is marked and
incised. B. The lymph nodes to be harvested are
located inferior to the lateral border of the pectoralis
minor muscle. C. As the flap is transposed into the

breast anteriorly the lymph nodes are swung upward
and placed in the axilla. (From Ooi AS, Chang DW. 5-
step harvest of supraclavicular lymph nodes as
vascularized free tissue transfer for treatment of
lymphedema. J Surg Oncol. 2017;115:63-67.)
■ Inguinal Vascularized Lymph Node Harvest
■ Based on the superficial circumflex iliac artery (SCIA) or occasionally on
the superficial inferior epigastric artery (SIEA).
■ The lymph nodes can be harvested alone or as part of an abdominal flap for
simultaneous breast reconstruction and VLNT.
■ For lymph nodes alone, the flap can be harvested with or without a skin
paddle.
■ Surface landmarks (TECH FIG 3A) are the anterior superior iliac spine
(ASIS), pubic symphysis, inguinal ligament, and the femoral canal.
■ Reverse lymphatic mapping is done for the side that lymph nodes are to be
harvested from. This first involves the preoperative injection of technitium-
99–labeled albumin into the medial thigh.
■ The skin incision is made 2 cm superior to the inguinal ligament and
deepened to the level of the cribriform fascia.
■ If a skin paddle is desired, a handheld Doppler probe can be used to detect
the perforators from the SCIA, along a line 1 to 2 cm inferior to the
inguinal ligament.
■ The SCIA and SIEA are identified. The lymph nodes are located in the fat
lateral to the SIE vessels and around the SCI vessels, superior to the inguinal
ligament (TECH FIG 3B). Their superficial border is the Scarpa fascia and
the deep boundary is the muscular aponeurosis.
■ A gamma probe is used to locate the sentinel lymph node in the leg via
reverse lymphatic mapping.
■ It is imperative that the sentinel lymph nodes along with the deeper lymph
nodes that drain the leg are not included in the flap.
■ Once the deep lymph nodes have been identified and kept away from the
dissection, lymph node harvest can be completed.
■ If an abdominal flap for breast reconstruction is planned together with the

VLNT, the lymph nodes should be harvested in continuity with the
abdominal tissue along the SIE and/or SCI vessels. The pedicle of the
abdominal flap (be it a perforator or muscle-sparing flap) is then
anastomosed to the internal mammary vessels, with supercharging of the
lymph node vein to an axillary recipient vein (TECH FIG 3C).9
■ The donor site is closed over a suction drain, ensuring that Scarpa fascia is
approximated before a running subcuticular suture for the skin. If an
abdominal flap is taken, this is closed in the usual fashion.
TECH FIG 3 • A. Surface landmarking of inguinal
lymph node transfer. B. The lymph nodes are located
in the fat lateral to the SIE vessels and around the SCI
vessels, superior to the inguinal ligament. C. The
pedicle of the abdominal flap is then anastomosed to
the internal mammary vessels, with supercharging of
the lymph node vein to an axillary recipient vein. (B,C:
From Ooi AS, Chang DW. 5-step harvest of
supraclavicular lymph nodes as vascularized free
tissue transfer for treatment of lymphedema. J Surg
Oncol. 2017;115:63-67.)

■ Omental Vascularized Lymph Node Harvest
■ The omentum has been called the guardian of the abdomen due to its
lymphatic and immunological capability.
■ The omental flap is based on the right gastroepiploic artery and can be
harvested via an open or laparoscopic approach. A skin paddle is not
possible.
■ For the open approach, an upper minilaparotomy incision is used.
■ For the laparoscopic approach, the abdomen is accessed with four ports.
■ The lymphatic territory of the omentum can be identified with methylene
blue dye injection preoperatively. This can be done using upper
gastrointestinal endoscopy or via direct injection using the open or
laparoscopic approach.
■ The free border of the omentum is first identified. This is then dissected
along its natural anatomical plane toward the greater curve of the stomach.
Gentle manipulation of the omentum is required throughout the harvest.
■ The lesser sac is entered and the short gastric and left gastroepiploic vessels
are identified and ligated, and the flap is dissected off the greater curve of the
stomach with meticulous cautery.
■ The flap is harvested in its entirety based on the right gastroepiploic artery,
which is dissected to its origin. It can be debulked by up to 40% to aid in
inset.
■ Preoperative dye mapping aids in preserving the critical lymphatic tissue.10
■ Once the flap is rendered ischemic, delivery of the flap extra-abdominally
can be done via the minilaparotomy incision or, in the case of the
laparoscopic approach, a 3-cm infraumbilical extension of the umbilical port.
■ The laparotomy or laparoscopic wounds are closed in the usual fashion.
■ Recipient Site Preparation and Microanastomosis
■ As mentioned previously, recipient site is dependent on clinical indication
and surgeon preference. The advantages and disadvantages of each are
summarized in Table 3.
■ In the upper extremity, the lymph nodes are commonly placed in the axilla or
at the dorsal wrist.
■ In the lower extremity, the lymph nodes are commonly placed in the groin,

anterior ankle and less commonly, the popliteal region.
Axilla
■ A skin paddle is usually not required for VLNT to this region.
■ If available, a previous axillary scar is used for the skin incision.
■ The incision is deepened toward the axillary fat, releasing and removing any
scar tissue. Care must be taken to avoid injury to vital structures within the
axilla.
■ The TD or LT vessels are identified and preserved. Arterial and venous
anastomosis is done end to end (ETE) to these vessels. The flap is placed in
the pocket created.
■ The axillary wound is closed over a suction drain. An implantable Doppler
probe can be used for monitoring of anastomotic patency.
Medial Elbow
■ The VLN flap is usually harvested with a skin paddle for this recipient site.
■ A curvilinear skin incision is made on the medial volar elbow area at the
level of the epicondyle.
■ A pocket is created for the flap placement.
■ The anterior recurrent ulnar artery and the basilic vein are identified and
used for ETE anastomosis.
■ The flap is inset loosely over nonsuction drains.
Table 3 Advantages and Disadvantages of Different Vascularized Lymph
Node Transfer Recipient Sites
Advantages
Disadvantages
Upper
extremity
Axilla
Hidden incision/scar
Scar tissue release
Multiple recipient vessels
Buried flap requiring
implantable Doppler
probe for monitoring of
anastomotic patency
Elbow
Hidden donor site scar
medially
Difficult dissection of
recipient vessels
Interruption with elbow
flexion
Wrist
Tension-free closure with
skin paddle
Ease of monitoring
Aesthetically displeasing
skin paddle
May require skin graft

Lower
extremity
Groin
Hidden incisional scar
Scar tissue release
Potentially deep
dissection
Buried flap requiring
implantable Doppler
probe for monitoring of
anastomotic patency
Posterior
knee
Hidden incisional scar
Difficulty with positioning
and microanastomosis
Ankle
Tension-free closure with
skin paddle
Ease of monitoring
Aesthetically displeasing
skin paddle
May require skin graft
Difficulty with footwear
Dorsal Wrist
■ The VLN flap is usually harvested with a skin paddle for this recipient site.
■ A transverse skin incision is used to create a pocket within which the flap
can be partially inset.
■ Arterial microanastomosis is done ETE to a superficial branch of the radial
artery at the anatomical snuffbox.
■ Venous microanastomosis is done ETE to a branch of the cephalic vein.
■ The skin of the VLN flap is loosely approximated to the wrist skin over
nonsuction drains to avoid compression.
Groin
■ A skin paddle is usually not required for VLNT to this region.
■ A vertically oriented linear skin incision is made at the medial groin beneath
the inguinal ligament and just above the femoral pulse.
■ Dissection proceeds toward the superficial femoral vessels, carefully
preserving any skin perforators or branches of the greater saphenous vein.
■ Any scar tissue is aggressively released and removed to create a pocket for
the VLNT.
■ Arterial microanastomosis can be done ETE to a branch of the superficial
femoral artery or an adequate skin perforator or end to side (ETS) to the
superficial femoral artery.
■ Venous anastomosis can be done ETE to a branch of the accompanying
femoral vein or a branch of the greater saphenous vein.
■ The axillary wound is closed over a suction drain. An implantable Doppler

probe can be used for monitoring of anastomotic patency.
Posterior Knee
■ For the rare occasions where the flap is to be placed at the posterior knee, a
skin paddle is usually not required.
■ A vertical skin incision is made medially just below the popliteal region.
■ A pocket is created for placement of the VLN.
■ Microanastomosis can be done ETE to the medial genicular branches or ETS
to the posterior tibial vessels.
■ Closure of the wound is done over a suction drain.
Dorsal Ankle
■ The VLN flap is usually harvested with a skin paddle for this recipient site.
■ A curvilinear incision is made on the dorsal ankle and deepened to the deep
fascia.
■ The superior and inferior skin envelopes are undermined to allow for the
inset of the VLN flap.
■ The dorsalis pedis (DP) vessels are identified and preserved for
microanastomosis. This can be done in an ETE or ETS fashion for both the
flap artery and vein.
■ The flap skin paddle is then loosely inset into the skin pocket over
nonsuction drains.
■ A split-thickness skin graft may be required in cases in which the sides of the
flap are too large to fit into the created skin pocket.
PEARLS AND PITFALLS
Assessment
■ Confirm the diagnosis of lymphedema and find out what therapy
has been tried.
■ Exclude smoking, hypercoagulable states, or bleeding tendencies.
Donor site
selection and
harvest
■ The surgeon should be comfortable with harvesting from the
chosen donor site.
■ Avoid harvesting the deep lymphatic chain of the thoracic and
groin lymph node basins to prevent donor limb lymphedema.
Recipient site
■ Selection of proximal or distal recipient sites is dependent on

selection
surgeon preference, familiarity, and comfort; also, the area of the
lymphedema, as well as discussion with the patient.
■ Release of scar tissue and the introduction of well-vascularized
lymph nodes can promote angiogenesis.
Postoperative
care
■ The vascularized lymph node transfer is a free flap, and
monitoring should proceed accordingly.
■ Compression therapy should be continued postoperatively.
POSTOPERATIVE CARE
■ Immediate postoperative care would include monitoring of the free VLNT
recipient site for anastomotic patency and local wound complications, as well
as monitoring of the donor site. Postoperative free flap care is unit dependent,
but usually would include:
■ Hourly monitoring of the flap using clinical parameters for the skin paddle or
implantable Doppler probe for buried flaps
■ Monitoring for development of hematoma at the recipient site
■ Monitoring for development of hematoma or lymphorrhea at the donor site.
The latter can usually resolve conservatively with prolonged drain use
■ Prevention of thromboembolic problems using mechanical and chemical
prophylaxis
■ The patient being kept NPO overnight for emergent flap take back if required
■ Early mobilization of patients on postoperative day (POD) 1
■ Early use of compression wrapping by trained lymphedema therapists
■ Patients are usually discharged on POD 3 or 4.
■ Follow-up would include regular clinic visits for monitoring for wound
complications and results of the VLNT. The latter is preferably done using the
same techniques as preoperative assessment of lymphedema severity.
OUTCOMES
■ The VLNT is like any free flap, requiring time for neovascularization and
lymphangiogenesis. Typically, objective measurement results are not seen until
1 year postoperatively. Patients often report symptomatic improvement almost
immediately postoperatively, especially in cases where scar tissue has been
excised and vascularized flap is placed.
■ As the technique of VLNT gains increasing popularity, the number of studies
reporting on its results are growing, with reduction rates of 0% to
100%.8,9,11–15 It is difficult to directly compare outcomes because there is a

wide range of donor and recipient sites, as well as severity of lymphedema.
■ In a 20-year follow-up of 1500 cases of VLNT, Becker et al. reported a
response rate of 98%, with 40% of patients with stage I and II extremity
lymphedema achieving a 100% reduction rate.8
■ In a study of 13 cases in which the supraclavicular VLNT was used for
lymphedematous limbs by Akita et al., there was an improvement in lower
extremity lymphedema index of 27% and a 54% improvement in lymphatic
function.11
■ In a study of seven patients receiving submental VLNT to the lower
extremity with a mean follow-up of 9 months, Cheng et al. reported
significant reduction in the volume of the lymphedematous limb of 23%
above the knee, 22% below the knee, and 27% above the ankle, with
reduction in episodes of cellulitis.7
■ In a study on 29 patients receiving simultaneous inguinal lymph node transfer
with abdominal-based breast reconstruction with a mean follow-up of 11
months, Nguyen et al. reported a 79% symptomatic improvement and mean
volume differential improvement of 10% at 12 months after reconstruction.9
COMPLICATIONS
■ Complications of vascularized lymph node transfer
■ Lymphedema of donor site
■ Donor site pain
■ Lymphorrhea
■ Wound infection
■ Flap failure
■ Hematoma
■ Recurrence of lymphedema
■ Complications of long-standing lymphedema
■ Infection
■ Sensory disturbance
■ Pain
■ Reduction in mobility
■ Reduced quality of life
■ Stewart-Treves syndrome (lymphangiosarcoma)
REFERENCES
1. Narushima M, Yamamoto T, Ogata F, et al. Indocyanine green lymphography

findings in limb lymphedema. J Reconstr Microsurg. 2015;32(01):072-079.
2. Dayan J, Dayan E, Kagen A, et al. The use of magnetic resonance
angiography in vascularized groin lymph node transfer: an anatomic study. J
Reconstr Microsurg. 2014;30(01):041-046.
3. Sapountzis S, Ciudad P, Lim SY, et al. Modified Charles procedure and lymph
node flap transfer for advanced lower extremity lymphedema. Microsurgery.
2014;34(6):439-447.
4. Chang DW, Suami H, Skoracki R. A Prospective analysis of 100 consecutive
lymphovenous bypass cases for treatment of extremity lymphedema. Plast
Reconstr Surg. 2013;132(5):1305-1314.
5. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping. Plast Reconstr
Surg. 2015;135(1):277-285.
6. Raju A, Chang DW. Vascularized lymph node transfer for treatment of
lymphedema. Ann Surg. 2015;261(5):1013-1023.
7. Cheng M-H, Huang J-J, Nguyen DH, et al. A novel approach to the treatment
of lower extremity lymphedema by transferring a vascularized submental
lymph node flap to the ankle. Gynecol Oncol. 2012;126(1):93-98.
8. Becker C, Vasile JV, Levine JL, et al. Microlymphatic surgery for the
treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39(4): 385-398.
9. Nguyen AT, Chang EI, Suami H, Chang DW. An algorithmic approach to
simultaneous vascularized lymph node transfer with microvascular breast
reconstruction. Ann Surg Oncol. 2015;22(9):2919-2924.
10. Nguyen AT, Suami H. Laparoscopic free omental lymphatic flap for the
treatment of lymphedema. Plast Reconstr Surg. 2015;136(1):114-118.
11. Akita S, Mitsukawa N, Kuriyama M, et al. Comparison of vascularized
supraclavicular lymph node transfer and lymphaticovenular anastomosis for
advanced stage lower extremity lymphedema. Ann Plast Surg. 2015;74(5):1-7.
12. Cheng M-H, Chen S-C, Henry SL, et al. Vascularized groin lymph node flap
transfer for postmastectomy upper limb lymphedema. Plast Reconstr Surg.
2013;131(6):1286-1298.
13. Lin C-H, Ali R, Chen S-C, et al. Vascularized groin lymph node transfer
using the wrist as a recipient site for management of postmastectomy upper
extremity lymphedema. Plast Reconstr Surg. 2009; 123(4):1265-1275.
doi:10.1097/PRS.0b013e31819e6529.
14. Sapountzis S, Nicoli F, Chilgar R, Ciudad P. Evidence-based analysis of
lymph node transfer in postmastectomy upper extremity lymphedema. Arch
Plast Surg. 2013;40(4):450.

15. Sapountzis S, Singhal D, Rashid A, et al. Lymph node flap based on the right
transverse cervical artery as a donor site for lymph node transfer. Ann Plast
Surg. 2014;73(4):398-401.

47
CHAPTER
Fasciocutaneous Debulking
of Extremity Lymphedema:
The Charles Procedure
Clifford C. Sheckter and Peter Johannet
DEFINITION
■ Lymphedema is the accumulation of interstitial fluid and fibroadiposity in
subcutaneous tissues as a result of dysfunction in the lymphatic system.
■ Compared with generalized edema, lymphedema by definition is caused by
poor lymphatic outflow (compared to increased capillary leak).1
■ The disease is generally described in terms of primary vs secondary (ie,
acquired) causes.1
■ Primary lymphedema: congenital (less than 2 years), praecox (first to third
decade of life), and tarda (greater than fourth decade of life).
■ Secondary lymphedema: malignancy, iatrogenic/surgery (most common in
developed world), obesity, trauma, and infection/filariasis (most common
worldwide).
■ Although nonoperative treatment is the mainstay, each case should be
evaluated individually. Surgical options including radical excision can offer
significant improvement.
ANATOMY
■ Lymphedema can occur anywhere in the body where lymphatics are present;
however, the disease tends to be most problematic within the extremities and
genitals.
■ In the extremities, the lymphatic system courses within the soft tissue between
the dermis and muscle fascia, and thus, the disease is confined to this area.
Anatomic knowledge of the subcutaneous tissues and its contents is crucial for
surgical treatment given many nerves run within or adjacent to muscle fascia.

■ Lower extremity considerations:
• Common peroneal nerve at fibular head
• Sural nerve at posterior calf
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Generalized edema due to any underlying medical disorder (heart failure, renal
failure, cirrhosis) or medication should be ruled out, given these causes are
often reversible with proper medical management.
■ Other limb-enlarging disorders should be considered including chronic venous
insufficiency, deep venous thrombosis, congenital musculoskeletal limb
discrepancy disorders, myxedema, and neoplasia.
■ For lymphedema, determine primary vs secondary lymphedema based on the
timing of onset, travel history (endemic filariasis), family history, and any
personal history of injury, surgery, or radiation.
■ Two-thirds of cases involve a single extremity; however, bilateral lymphedema
is possible depending on the nature of injury (eg, pelvic lymph node
dissection).2
■ Examination of affected limb reveals supple tissue that often “pits” when
gently pressed. Long-standing lymphedema causes skin changes including
thickening of the dermis and thickening of the epidermis (hyperkeratosis).
■ The classic Stemmer sign is considered positive when the examiner is unable
to pinch the skin on the affected side at the dorsum of second toe or second
finger. The unaffected side will easily tent when gently pinched.3
■ Measuring the affected limb is important both in terms of comparison to the
normal side (if present) and assessing for improvement with anticipated
therapy.
■ Volumetric measurements are the standard and can be achieved through
either estimated circumference measurements or water displacement testing.
• Circumference measurements, while easily accessible, can be plagued by
poor interrater reliability.4
• Water displacement testing, whereby the affected limb is submerged into
large containers, is highly precise, albeit cumbersome. Volume in excess of
200 cc (compared to normal side) is considered diagnostic.4
IMAGING
■ In general, imaging is not necessary for diagnosis with a convincing history

and physical exam. If there is uncertainty in diagnosis, tailored imaging can
assist in excluding/confirming lymphedema. For surgical planning, some
surgeons advocate for ultrasound to ensure competency of the deep venous
systems.
■ Ultrasound can evaluate for deep venous thrombosis.
■ Computed tomography can evaluate for masses, lipodystrophy, venous
thrombosis, and lymphedema with high sensitivity.
■ Lymphoscintigraphy can help confirm the diagnosis through demonstrating
both quantitative and qualitative impairment in trace.
■ Indocyanine green lymphangiography can assist in delineating drainage
patterns and is more often employed in the preoperative planning of
lymphovenous anastomosis or vascularized lymph node transfer.
SURGICAL MANAGEMENT
■ There are limited prospective studies comparing the different treatments of
lymphedema, particularly surgical approaches. There is no defined period of
waiting or algorithm for performing the different procedures.
■ In general, nonoperative therapy is considered first line,1 largely consisting of
concentric extremity compression wrapping with or without mechanical
compression. Surgery is usually reserved for those patients with the following
characteristics:
■ Failed compression therapy
■ Recurrent soft tissue infection and/or cellulitis
■ Quality of life limitations such as pain, limited mobility, and psychosocial
distress
■ Operations are classified into two categories: physiologic and ablative.
■ Physiologic procedures involve three techniques
• Creating new lymphatic anastomoses (lympholymphatic bypass).
• Diverting lymphatic drainage into the venous system (lymphovenous
bypass).
• Autotransplanting lymph nodes from another part of the body (vascularized
lymph node transfer). These techniques have their own chapter for further
discussion on technique.
■ Ablative techniques involve directly removing tissue from the affected
extremity and fall into two operations:
• Liposuction

• Direct excision
■ Direct excision is further characterized based on reconstruction modality: skin
graft vs flap.
■ Originally described by Sir Richard Henry Havelock Charles in the early
20th century from his proceedings in India, the surgery attributed to Charles
involves radical debridement of all soft tissue superficial to skeletal muscle
with placement of skin grafts from the excised tissue onto the limb muscle.5
■ Staged excision: the lower extremity is excised in at least two operations
staged 3 months apart. Thick tissue flaps are elevated 1 to 2 cm in thickness
and then underlying soft tissue is excised down to muscle fascia. Flap skin
edges are closed in a single dermal layer using permanent suture (eg, 3-0
nylon). This procedure shares eponyms including Homans, Sistrunk, and
Thompson procedure.
■ Though effective in terms of reducing limb volume, the Charles procedure
unequivocally yields a poor cosmetic result, which some patients are willing to
accept given the burden of lymphedema (FIG 1).
■ Although the authors do not perform physiologic techniques for
lymphedema, it is reasonable to attempt these procedures first, given the
lower morbidity.
■ More recent advances in lymphovenous anastomosis and vascularized lymph
node transfer have shown some successes in reducing limb circumference, yet
for patients with significant soft tissue redundancy, surgical excision still
plays a significant role.
■ Reports of combined lymph node transfer with a Charles procedure have
been described.6,7

FIG 1 • Preoperative photo of a lower extremity with
severe lymphedema.
Preoperative Planning
■ Volumetric measurements should be obtained as mentioned above. This allows
for postoperative comparisons to demonstrate effectiveness.
■ Ultrasound can be useful in assessing the deep venous system to ensure
competency.
Positioning
■ Majority of cases will only involve a single lower limb; however, even if
multiple extremities are involved, only one extremity should be excised at any
given time the significant morbidity of the procedure.
■ The patient is positioned in supine with the leg prepped circumferentially and
free. A sterile tourniquet will assist in accessing more proximal upper leg in the
event this tissue is involved.
Approach
■ This is an elective procedure and should only occur when the patient is free of
infection (ie, cellulitis) and healthy. If soft tissue infection exists, there is
higher likelihood of graft failure.
■ General anesthesia due to pain and inability to use local anesthesia due to large
surface area.
■ Consider regional anesthesia blocks and even an epidural if feasible.
T E C H N I Q U E S
■ Radical Fasciocutaneous Debridement With Split-
Thickness Skin Grafts (Charles Procedure)
■ After the limb has been prepped and draped in sterile fashion, all tissues
planned for excision are marked and delineated.
■ Skin graft harvest trajectories are planned based on surfaces of greatest
convexity with longest length (avoid anterior and posterior harvest over