Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

e26
PART 1 — PRINCIPLES
induce incoming blood vessels (angio-induction) and as a
scaffold to guide outgrowth of blood vessels. To further
enhance vascularization, proangiogenic endothelial pro­
genitor cells can be seeded into this framework.4 These
phenomena can be induced by an in-situ or ex-vivo approach.
With in-situ cultivation of cells and tissues, the patient’s
own body is used as incubator. Such a strategy sounds logical
and efficient. However, infiltration of undesired tissues and
the obligatory use of shaped biocompatible implants as scaf­
fold make this approach far from evident.
On the other hand, an ex-vivo approach to overcome the
invasion of undesired tissues requires an immediate reper­
fusion once the regenerated tissue is “transplanted” in situ.
Moreover, the ex-vivo revascularization step should occur in
an incubator that mimics the real-time wound environment.
Such strategy is also not evident.
Both approaches are intensively investigated.
PROANGIOGENIC STRATEGIES
The most obvious strategy focuses on adding proangiogenic
molecules to the recipient tissues or the scaffold: growth
factors such as VEGF, bFGF, PDGF, IGF-1 function as coor­
dinators of the wound healing process, turning a temporary
scaffold into a vascularized scaffold by attracting vascular
progenitor cells, which will interact with local cells to grow
a vascular network in situ.4,9 These proangiogenic proteins
are secreted by the cells in a specific sequence. In an in vivo
model, these processes occur spontaneously once the cells
are added to the wound. In a hostile milieu, missing cells
and growth factors could be added to induce healing and
integration. However, the half-life of externally added pro­
teins to the healing wound is very short. In-vivo and ex-vivo
gene transfer protocols may overcome the short-acting
effect of proteins by turning local cells into production units
of those proangiogenic growth factors. Nevertheless, to
avoid tumor growth, it is essential to control this proangio­
genic stimulus.4,9–11
In a clinical setting, prefabrication and prelamination
techniques can be used to induce the formation of a mac­
roscopical, transplantable vascular supply to tissues or tissue
constructs. Similarly, hypoxia and inflammation in response
to wounding are triggers to induce angiogenesis.12
Recent proof-of-principle strategies combine engineering
with biomolecular approaches. Miller and colleagues
described 3-dimensional printed networks of carbohydrate
glass-molds coated with PLGA-copolymer. Constructs were
encapsulated in a range of hydrogels along with living cells.
Following ECM cross-linking, glass particles were dissolved
to reveal patent fluidic PLGA-channels.13
An alternative approach is the use of photo-cross-linkable
gelatin methacrylate using projection stereolithography
based on computer-aided design.14 The advantage of CAD/
CAM-design is the large-scale reproducibility and the
patient-specific scaffold production through the combina­
tion with CT-imaging.
Another option is to use stacking strategies, coined “cell-
sheet engineering.” A temperature-responsive surface is
used to culture cells. Upon reaching confluency, the surface
can be cooled to 20°C to reduce its hydrophobicity, and the
intact cell sheet can be removed, preserving cell-to-cell junc­
tions, ECM and cell-surface proteins. These cell sheets can
then be stacked to generate multi-layered, cell-dense tissues.
Stacked layers of cardiomyocytes that beat simultaneously
MECHANISMS OF ACTION
CURRENT STRATEGIES IN TISSUE
ENGINEERING
Three major approaches have been established toward engi­
neering implants for regeneration: (1) implantation of engi­
neered scaffolds and matrices; (2) implantation of neo-tissue
derived from cells; (3) implantation of cells seeded within
matrices.7
COMPLEX SCAFFOLDS AND MATRICES
The optimal bioengineered substitute must have a structure
similar to the authentic tissues it must replace. It should
be autologous to optimally integrate without rejection, 3-
dimensional to bridge deep defects, porous to allow cell
migration, bio-inductive for cells to proliferate and to topi­
cally produce extracellular matrix (ECM) components and
growth factors, bio-inductive for vascular sprouts to develop
within the construct and chemotactic for cells from the
wound surroundings to infiltrate, stimulate vasculogenesis
and optimize tissue integration.3,6 When selective absorp­
tion of the matrix occurs, its composition and structure
should be maintained. The absorption process should not
result in deposition of toxic side products. The accompany­
ing inflammatory response should be limited not to hamper
cellular migration and repopulation stimulated by site-
specific cues for cellular adhesion. This extensive list of
requirements is self-explicatory as to why the ideal off-the-
shelf scaffold has not been developed yet, despite the
detailed knowledge of many biocompatible materials. It is
the collaboration between material scientists, chemists,
clinicians, and molecular biologists that forms the multidis­
ciplinary environment required to design a veritable biomi­
metic smart scaffold.5
FUNDAMENTAL ROLE OF VASCULARIZATION
The absence of a vascular network capable of distributing
oxygen and nutrients within the matrix is the key limiting
factor in the overall success of tissue engineering. Nutrient
supply and waste removal of limited-thickness engineered
tissues such as skin, cartilage, or bone can initially be over­
come by diffusion, until neovascularization takes over. In
1973, Folkman demonstrated that cells only survive within
a 3-mm distance from a nutrient source.8 From clinical evi­
dence using artificial dermis in burn patients, we estimate
the critical thickness to be even less, between 1 and 2 mm.
The ultimate purpose of tissue engineering is to incorporate
an inherent vascular bed, ready to be connected to the host
vascular system. A viable vascular network within the tissue
construct represents the missing link between the host and
the engineered implant.
The adult vascular network remodels itself by the enlarge­
ment of existing collaterals induced by shear forces, as well
as by angiogenesis; the coordinated migration and prolifera­
tion of endothelial progenitor cells and pericytes from the
existing vascular bed and their subsequent maturation into
endothelial cells, stabilized by these enveloping smooth
muscle cells. The primary stimulus causative for capillary
sprouting is hypoxia. The extracellular matrix functions as
a reservoir of guidance molecules, i.e. growth factors that

CHAPTER 6 — Tissue Engineering
e27
(iPSCs) possess a differentiation potential equal to human
embryonic stem cells. In other words, they are capable of
differentiating into tissues of all three germ-cell layers given
the correct culture conditions, growth factors, and genetic
milieu.
As these cells are derived from adult tissues, there are no
ethical issues. Another advantage is the possible autologous
source of the stem cells, unlike embryonic stem cells. Nev­
ertheless, iPSCs also carry the risk of teratoma formation
and genetic instability. At the moment, these cells cannot
be efficiently used in clinical, reconstructive settings.21
MULTIPOTENT STEM CELLS FOR USE IN
AUTOLOGOUS CONDITIONS
Multipotent stem cells are capable of differentiating into
multiple cell types. Adult stem cells or organ, specific stem
cells can be isolated from several tissue sources, including
bone marrow, peripheral blood, skeletal muscle, central
nervous system, retina, adipose tissue, and epithelia of skin
and digestive tract. Multipotent stem cells from lipoaspirates
are extensively investigated and used in a clinical recon­
structive context.22–24
These cells preferentially generate differentiated cells of
the same lineage as their tissue of origin. However, experi­
ments suggest that adult stem cells from various organs
could contribute to the regeneration of dissimilar organs
with stem cells crossing germ layers. This process is called
transdifferentiation. This has led to the suggestion of a “stem-
cell highway”, in which stem cells can transit through the
circulation with access to all organs. Homing signals (the
“niche” or microenvironment) might influence stem-cell
migration to specific sites. Secreted growth and differentia­
tion factors are important extracellular signals that control
stem-cell fate.25,26 Still, vigilance is essential when using adult
multipotent stem cells, since ex vivo culture of mesenchymal
stem cells promotes chromosomal instability.27
UNIPOTENT PROGENITOR CELLS
Blood Outgrowth Endothelial Cells
Lin et al and Yoder et al characterized late outgrowing
endothelial-like colonies of collagen-adherent cells with
much higher proliferation capacity than early-outgrowth
endothelial progenitor cells (EPCs).28,29 These cells are
named blood-outgrowth endothelial cells (BOECs). BOECs
stimulate angiogenesis actively by incorporation into the
host vessel, and passively by secretion of proangiogenic
growth factors. BOECs can be isolated from umbilical cord
blood or adult blood, with the former showing higher pro­
liferation potential but also susceptibility to karyotypic
aberrations.29–31
In the future, these stem cells, derived from autologous
tissues, may play a growing role in cell-based tissue-
engineering techniques. Meticulous identification and puri­
fication will be essential to ensure predictability and safety
in clinical protocols.31,32
TISSUE ENGINEERING-BASED CLINICAL
APPLICATIONS
In 1997, Cao and colleagues33 published a report of an
athymic mouse with a human ear grown on its back. This
without the use of a formal scaffold are a powerful example
of this method.15
A controlled induction of vascular networks by ex-vivo or
in-situ strategies will determine when tissue engineering will
be incorporated successfully and substantially in clinical
practice.
DECELLULARIZATION OF TISSUES TO OBTAIN
THE IDEAL SCAFFOLD
Decellularization is an approach that removes resident cells
from a tissue or even an organ. This cellular removal can
be achieved by physical, chemical and enzymatic methods.
The aim is to preserve the native structure and function of
the ECM, including its perfusable vasculature. These decel­
lularized matrices can be re-seeded and repopulated with
autologous cells to restore morphology and function. The
strength of this approach may be the preservation of bio­
molecular environmental cues that are likely to direct cel­
lular phenotype.16
Song and colleagues decellularized cadaveric rat kidneys
via detergent-perfusion through the renal artery. Acellular
scaffolds were repopulated with human umbilical venous
endothelial cells and rat neonatal kidney cells. After seeding,
the organs were transferred to a perfusion bioreactor to
provide whole-organ culture conditions. Upon transplanta­
tion in vivo, urine was produced.17
The primary aim of such decellularization strategies is to
deplete the tissues and organs of their immunogenic ele­
ments and to repopulate them with autologous cells. Similar
whole-organ decellularization methodologies are tailored
for heart, liver, lung and trachea.
CELLS AND STEM CELLS: THE SUBSTRATE
Scaffolds deliver the structural guidance and support for
proliferating and migrating cells through their honeycomb
structure. They transmit tissue-specific mechanical forces
that cue the behavior of cells within it. The appropriate
parenchymal-cell populations, are the living building units
of new tissues. They are elementary in the generation of
3D-tissues that can be incorporated into the defect.18
Cell cultivation allows expansion of the number of cells
procured from a small tissue biopsy. However, adult cells
may be limited in growth potential, may differentiate too
easily, or may rapidly deteriorate by senescence. Stem cells
could overcome these problems. Stem cells have the unique
ability to self-renew, proliferate indefinitely, and create off­
spring that differentiates into specialized, mature tissues by
asymmetric replication.19 Nevertheless, stem cells, represent
a miscellaneous group of cells, with different levels of dif­
ferentiation potential. From a clinical reconstructive per­
spective, it is desirable that they are derived from autologous
tissues to avoid immune-mediated reactions.
PLURIPOTENT STEM CELLS FOR USE IN
AUTOLOGOUS CONDITIONS
Induced Pluripotent Stem Cells
In 2006, Takahashi and Yamanaka reported how adult
human dermal fibroblasts or other human somatic cells
could be directly reprogrammed by the introduction of
transcription factors.20 Induced pluripotent stem cells

e28
PART 1 — PRINCIPLES
These scaffolds could be applied for short periods to
stimulate autologous healing, serving as biological dressings.
Cell-free biodegradable scaffolds may stimulate colonization by
autologous cells in the wound environment. Cell-containing
skin substitutes may provide immediate functional skin
replacement. However, in a clinical context, allogenic cells
will be rejected.
Skin substitutes can also be divided according to the
skin layer they represent: epidermal, dermal or combined
(Table 6.1).
EPIDERMAL SUBSTITUTES
Cell engineering42 emerged from the discovery that human
keratinocytes could be cultivated and differentiated on a
carpet of irradiated murine 3T3-fibroblasts in a culture dish
in appropriate tissue-culture conditions.43,44 This break­
through led to the application of cultured autologous kera­
tinocytes on burns in 1981 and later proved to be life-saving
in extensive burn wounds with limited donor site for skin
grafts. However, graft-take remained below 70% in more
than 50% of cases. Even after healing, the reconstituted
epidermis remained excessively fragile, mainly due to loss
of the rete-peg pattern of the epidermis.45,46
In order to restore function and structure of the skin, an
epidermal layer will not suffice.
DERMAL SUBSTITUTES
Hence, dermal substitutes were added in a partnership
with skin cells. In analogy with the extracellular matrix, the
scaffold provides support for dermal fibroblasts and epider­
mal keratinocytes. Preliminary clinical results on the use of
“artificial skin” in 1981 indicated better or equivalent per­
formance of the artificial dermis but poor resistance to
infection.37 The rationale of using an absorbable artificial
dermis on deep wounds is to provide a temporary scaffold
into which cells can migrate from the wound environment.47
Therefore, pore-size should be around 100–250 µm. The
collagen-glycosaminoglycan architecture of most dermal
scaffolds approaches that of normal dermis and completely
biodegrades within 30 days. Faster biodegradation might
lead to toxic byproducts that impair healing.48 Major
histocompatibility complex (MHC) class-I and class-II anti­
gens are found on cellular components of epidermis and
dermis. During the processing of acellular dermis, these
MHC-molecules are fully eliminated but reappear following
grafting, indicating that cells can invade the scaffold
and pore size is sufficient. When the basement membrane
of the substitute is preserved, keratinocyte-engraftment is
superior.49
COMPOUND SUBSTITUTES WITH EPIDERMAL AND
DERMAL ELEMENTS
Recently, compound scaffolds were presented featuring
dermal matrix-elements in combination with allogenic
foreskin keratinocytes and/or fibroblasts (Table 6.1).
Thus far, however, none of these cell-containing artificial
skin-equivalents has proven to add a significant clinical
advantage to healing parameters, despite their highly-
corresponding structure and bio-content. This explains why
none of the engineered cell-containing skin substitutes has
been approved for the European market yet. The cells
added are often allogenic and will therefore be rejected
ear consisted of an ear-shaped cartilage structure, implanted
subcutaneously. The group seeded the synthetic, biodegrad­
able mold with bovine chondrocytes. This report was
viewed worldwide and ignited the fascination for tissue
engineering.
Walles performed a Medline search using the term
“tissue engineering”, which provided 37,000 hits.34 The
majority were proof-of-principle studies, only a few resulted
in clinical protocols. For instance, in the context of auricu­
lar cartilaginous reconstruction, more than 20 studies
have been published in the past decade using cell-based
techniques and matrices for ear reconstruction. Clinical
engineering however, has only been reported in singular
cases. Major shortcomings are resorption of the biological
scaffold and collapse of the construct in an in-vivo clinical
setting.35
The progression from bench to bed in other tissue-
engineering protocols has also been hampered by many
difficulties, mostly related to insufficient vascularization and
loss of tissue strength and coherence.
In this section, clinical translational tissue-engineering
applications for skin, urethra and bladder, bone, trachea
and the cardiovascular system will be discussed in more
detail.
SKIN
Reconstitution of skin wounds deeper than the basement
membrane requires a restoration of all components to
restore thickness, texture, and elasticity, while providing bio­
mechanical resistance to aggressors. Skin substitutes were
developed for clinical use to treat extensive wounds such as
third-degree burns.36–38
Distinct features categorize skin substitutes or skin
equivalents:
Natural polymers used in skin tissue-engineering include
chitosan, fibrin, gelatin, and hyaluronic acid. Chitosan, a
polysaccharide acting as an analog to glycosaminoglycan, is
biodegradable and biocompatible. It is used as a hemostatic
agent and possesses antibacterial properties. Hyaluronic
acid shows excellent biocompatibility. Disadvantages of
natural polymers include low mechanical strength, shrink­
age and contraction, rapid biodegradability and risk of
immunological rejection.
Synthetic materials include nylon, polyglycolic acid and
polylactic acid. Due to the ease of fabrication, synthetic
polymers such as nylon (Biobrane®, TransCyte®) and poly­
glycolic acid/polylactic acid (Dermagraft®) are less expen­
sive. However, synthetic materials possess limited tissue
compatibility, cellular recognition, and incorporation.
These substitutes show their importance mainly in combina­
tion with natural polymers.39–41
Skin substitutes can also be described according to cell
content; cell-free (acellular) versus cell-containing (cellular)
substitutes:
• Acellular products contain matrix only, based on natural or
synthetic materials. These products serve as a template
for dermal reconstitution, allowing migration of host cells
during wound healing.
• Cellular products contain living cells such as keratinocytes
and/or fibroblasts with or without matrix.

CHAPTER 6 — Tissue Engineering
e29
surgically prepared wound-bed. It seems probable however,
that the next generation of off-the-shelf full-thickness skin
substitutes will emerge from these scientific data.
DE-NOVO ASSEMBLY OF MATRICES
In order to mimic structural and functional properties of
human extracellular matrix, new techniques are being
developed. The electrospinning of polymeric nanoscale-
fibers such as collagen has shown excellent results and this
technique is relatively easy and inexpensive.50 Collagen
nanofibrous scaffolds possess a structure mimicking native
within a 2-week timespan, similar to an allograft in a clinical
setting. Consequently it is the growth-factor boost of these
allogenic cells in the wound-healing environment that
may accelerate repair, and not the cells as such. On the
other hand, if autologous cells are seeded into the substi­
tute, the handling protocol becomes elaborate because the
cells must be obtained from an autologous biopsy. There­
fore, the processing of these substitutes is very costly and
time-consuming.
Because of these parameters, more studies are required
to evaluate the added value of compound sub­stitutes in a
clinical context, compared to full-thickness skin grafts on a
Table 6.1  List of Biological and Composite Skin Substitutes
Materials
Composition
Thickness
Brand
Indication
Biological
Alloderm
Acellular human dermis
0.79–3.3 mm
Lifecell Corporation, NJ, USA
Burns, soft tissue defects
Allomax
Acellular human dermis
0.8–1.8 mm
Bard Davol, RI, USA
Soft tissue defects
DermaMatrix
Acellular human dermis
0.2–1.7 mm
Synthes, PA, USA
Soft tissue defects
Glyaderm
Acellular human dermis
0.2–0.6 mm
Beverwijck, The Netherlands
Full thickness wounds
Graftjacket
Acellular human dermis
1; 1.4; 2 mm
Wright Medical Technology,
TN, USA
Soft tissue defects
Oasis
Porcine small intestine
submucosa acellular collagen
0.15–0.3 mm
Healthpoint Ltd, TX, USA
Burns, chronic wounds
Permacol
Acellular porcine dermis
0.4 or 1.5 mm
Covedien, OH, USA
Full thickness wounds
Strattice
Acellular porcine dermis
1.5–2 mm
LifeCell, NJ, USA
Soft tissue reconstruction
SurgiMend
Acellular bovine dermis
0.4–1.54 mm
TEI Biosciences, MA, USA
Soft tissue reconstruction
Tiscover
Acellular human dermis
autologous FB
1–2 mm
A-SKIN, BV, The Netherlands
Chronic wounds
Xenoderm
Acellular porcine dermis
0.3 mm
MBP Neustadt, Germany
Full thickness wounds
Composite
Apligraf
Allogenic neonatal FB
0.4 mm
Organogenesis, MA, USA
Donor sites, EB
Allogenic neonatal KC
0.75 mm
Dermagraft
Mesh + allogenic FB
0.19 mm
BioHealing, CA, USA
Wounds, diabetic ulcers
Hyalomatrix
Hyaluron-based scaffolds
with autologous FB
1.2 mm
Fidia
Burns, chronic wounds
Integra
Human collagen I with GAG
and silicone top
1.3 mm
Integra Life Sciences, NJ, USA
Burns, chronic wounds
Matriderm
Bovine collagen I, elastin
1 and 2 mm
Care AG, Germany
Burns, chronic wounds
OrCel
previously CCS
Collagen I sponge gel
allogenic FB and KC
1 mm
Ortec International, NY, USA
Chronic wounds, donor
sites
Renoskin
Bovine collagen I and GAG
1.5–2.5 mm
Perouse Plastie, France
Burns, defects
Terudermis
Calf collagen polyester mesh
± silicone top
4 types
Olympus Terumo Biomaterials,
Japan
Burns, mucosal defects
TransCyte
Collagen with neonatal FB
nylon mesh + silicone top
1.2 mm
Sciences, Inc, CA, USA
Burns
The composition of the substitute is represented in column 2, the thickness of the substitute is shown in column 3. Note that not all these
substitutes are available worldwide. Also, they may not be approved for the same indication in different countries. None of the engineered
cell-containing skin substitutes has been approved for the European market. FB = fibroblast, KC = keratinocyte, GAG = glycosaminoglycan

e30
PART 1 — PRINCIPLES
15 to 27 months, they reported abundant callus formation
along the implant and good integration with the host bone
by the second month after surgery.61
Warnke et al used a cell-based strategy to treat mandibular
defects after oncological resection. The authors used a tita­
nium mesh-cage filled with bone-mineral segments. They
added bone-morphogenetic proteins and bone marrow.62
The construct was matured into the latissimus dorsi muscle
for seven weeks. The group reported a substantial improve­
ment in quality of life of the patient. Despite exposure
to oral flora due to fracture of the titanium mesh and
partial infection of the regenerated bone, the mandible
replacement retained its function over 13 months after
transplantation.63
TRACHEA
The trachea has a longitudinal flexibility and lateral rigidity
to withstand the rigors of negative pressures during respira­
tion and to allow mobility during deglutition, speech
and movements of the neck. Moreover, the trachea has
a well-vascularized mucosal lining that serves as a primary
host defense mechanism against toxic particles present
in air.12
At first sight, it may appear relatively easy to generate a
hollow tube that mimics the windpipe. However it is very
complex to create a long, Pleonasm flexible vascularized
tube that has a mucosal lining with ciliated epithelium.64
Delaere et al used a trachea allotransplantation strategy
to restore long-segment defects of the trachea. A donor
trachea was prelaminated in the forearm and native allo­
genic mucosa was replaced with recipient mucosa.65 This
allowed for stopping of immunosuppression after ortho­
topic transfer to the defect in a second stage.66 Using their
prelamination protocol as a vascular platform, they cur­
rently investigate decellularization of the allotrachea to
further diminish immunogenicity and autologous cell-
cultivation to induce faster re-epithelialization.12
Kojima and Vacanti reported in 2004 a strategy forming
a tube with sheets of bioresorbable PGA seeded with autolo­
gous fibroblasts and chondrocytes from the nasal septa of
sheep. This construct was then implanted under the sterno­
cleidomastoid muscle to allow for extrinsic vascularization.67
The concept was innovative but unfortunately grafts col­
lapsed upon orthotopic transfer.
Omori et al reported in 2005 the first human case applying
regenerative medicine principles to partially restore the
cricoid cartilage and cervical trachea.68 They used an acel­
lular biosynthesized polypropylene-reinforced mesh coated
with collagen and preclotted with autologous blood, in four
human cases with a 8- to 34-month follow-up. In a canine
model, the same group added fibroblasts and bone marrow-
derived cells.69 The authors were skeptical about the durabil­
ity of regenerating cartilage from implanted chondrocytes.
By coating the lumen of the construct with poly L-lactic-acid-
co-caprolactone, which delays degradation of collagen, they
were able to promote migration of the host’s epithelium
onto the collagen layer.70
In 2008, Jungebluth et al treated a patient for end-stage
bronchomalacia by means of a decellularized donor trachea.
(Fig. 6.2) Short-term incubation was performed with autolo­
gous chondrocytes differentiated from bone-marrow derived
extracellular matrix. They possess excellent biocompati­
bility with similar cellular organization, proliferation and
maturation compared with current techniques such as
freeze-dried collagen.51
The future in ready-to-wear custom-made skin requires
enormous advances in the field of extracellular matrix
biology, since these skin substitutes should thrive in aber­
rant healing conditions when vascularization is impaired,
chronic inflammation exists, or proteinases are abundantly
present; e.g. in a diabetic patient, under cytostatic drugs or
corticosteroids.
Adding biomolecular cues of wound healing and tissue
regeneration to the 3-D scaffold might anticipate these
adverse healing events creating a “smart” tissue-scaffold in
which tissues migrate, integrate, and proliferate.52–55
URETHRA AND BLADDER
Approximately 400 million people worldwide suffer from
urinary bladder cancer. When radical cystectomy is per­
formed, the intestine is frequently used for urinary bladder
reconstruction. However, complication rates up to 56% are
reported.56
Atala et al treated seven patients in need of a cystoplasty
using adult autologous urothelial and muscle cells from a
bladder biopsy grown in culture. These cells were seeded
on a biodegradable bladder-shaped scaffold made of colla­
gen, or a composite of collagen and polyglycolic acid (PGA).
About 7 weeks after the biopsy, the engineered bladder was
used for reconstruction and implanted either with or
without an omental wrap. They reported excellent results
in a follow-up period of 22–61 months.57 Postoperatively, the
mean bladder leak-point pressure decrease at capacity, and
the volume and compliance increase were greatest in the
composite engineered bladders with an omental wrap.
Nevertheless, the construction of neo-bladder for patients
with muscle-invasive bladder cancer is much more challeng­
ing because of the inability to use autologous stem cells
derived from the urinary tract.58 This limitation demands
searching for new sources of stem cells.
Raya-Rivera et al reported a clinical tissue-engineering
strategy to restore long defects of the urethra in 5 patients.
They cultivated smooth muscle cells and epithelial cells
obtained from bladder biopsies. These cells were cultured
for 1 week to ensure migration, proliferation, and matrix
production and were then seeded onto tubular PGA: poly-
lactide-co-glycolide-acid (PLLA-PGA) scaffolds. The authors
confirmed that tissue organization of these scaffolds was to
native tissue. They reported excellent functional flow rates
at 36–76 months.59
In 1990, Romagnoli et al reported two patients treated
with cell sheets of serially cultivated autologous urethral
mucosal cells to treat posterior hypospadias.60 No scaffold
was used. The cells were directly applied in situ and mounted
on petrolatum gauze. The reported physiological function
at follow-up after 6 and 18 months was excellent.
BONE
Quarto et al seeded expanded osteoprogenitor cells on a
macroporous hydroxyapatite matrix to treat long bone
defects in three patients of various ages. In a follow-up of

CHAPTER 6 — Tissue Engineering
e31
Figure 6.2  Stem cell–based tissue engineered tracheal replacement. (1) Autologous epithelial cells were obtained from a nasal biopsy and
seeded onto the internal surface of the decellularized donor scaffold. (2) Autologous mesenchymal stem cells, obtained from the
mononuclear fraction of a bone-marrow biopsy, were differentiated into chondrocytes. (3) A decellularized tracheal tube was seeded with these
cells in a bioreactor. Granulocyte-colony stimulating factor (G-CSF) and topical human recombinant erythropoietin (EPO) were injected into the
scaffold. (4) After 96 h in the bioreactor, the graft was implanted clinically. In the initial report in 2008, the authors did not make use of vascu­
larized tissue to wrap around the construct.71 However, all trachea reconstructions so far treated with this strategy failed due to instability of
the construct.
2. MNCs from
iliac crest
4. G-CSF and EPO
administered
G-CSF and EPO
administered -
pre- and
postoperatively
Graft implanted
3. Natural scaffold
1. Nasal
epithelial
cells

e32
PART 1 — PRINCIPLES
thrombosis or stenosis of the graft. There was no reported
aneurysm or graft rupture.81
Olausson et al used a decellularization procedure on a
donor iliac vein and re-seeded it with endothelial and
smooth muscle cells derived from bone marrow of the recip­
ient. This procedure was used in a 10-year-old patient with
portal vein thrombosis. This first construct failed after 1 year
due to mechanical obstruction by tissue from the mesoco­
lon, but a similar second procedure led to normal portal
blood flow.82
CELL THERAPY FOR MYOCARDIUM
Vrtovec et al reported a 5-year follow-up of patients treated
with intracoronary CD34+ stem-cell transplantation in non-
ischemic dilated cardiomyopathy.83 Their study revealed
that transplantation might be associated with improved ven­
tricular function, exercise tolerance and long-term survival.
Bolli et al reported in the Lancet in 2011 the early func­
tional results of a phase-1 trial using cardiac stem cells
isolated from autologous atrial appendages in patients
with ischemic cardiomyopathy. Their approach led to
enhanced function following myocardial infarction and
failure of coronary stents.84
HEART VALVES
Mechanical valves85 offer exceptional durability coupled
with a considerable risk of thrombogenesis. Biological valves
do not need anticoagulation, but have a limited life span.
The concept of tissue engineering is based on the repopula­
tion of biological decellularized scaffolds with autologous
cells, creating an immune-privileged heart valve resistant to
degeneration and with the potential to grow.
In 2006, Cebotari et al reported the clinical implantation
of a decellularized human allogenic pulmonary heart valve,
which was re-seeded with mononuclear cells isolated from
human blood, including the EPC-fraction. Enzymatic treat­
ment with trypsin/EDTA converted pulmonary valves in a
cell-free scaffold with 98% reduction of DNA-content. His­
tology revealed a well-preserved 3-D network of collagen
fibers in extracellular matrix. They reported 3.5 years of
follow-up in two patients aged 13 and 11. Postoperatively, a
mild pulmonary regurgitation was documented in both chil­
dren, however no signs of valve degeneration were observed.
They showed that, in contrast to conventional homograft
and xenografts, decellularized fresh allograft valves exhib­
ited the potential to remodel and grow accordingly to the
somatic growth of the child.86
The same authors treated 131 patients with decellularized
pulmonary homografts from 2005 to 2015. Because of the
observation of spontaneous recellularization by several
groups, they implanted non-seeded valves. They demon­
strated promising superior results related to durability of the
constructs, e.g. related to freedom of explantation, develop­
ment of relevant gradients, compared to cryopreserved pul­
monary homografts and bovine jugular vein conduits.87
CONCLUSION
Plastic and reconstructive surgeons must embrace tissue
engineering and regenerative medicine. We have the soft
tissue handling and knowledge about remodelation.
MSCs and with autologous nasal epithelial cells.71,72 At eight
months, the patient developed a ventral collapse within the
proximal graft. It could be that ischemia was, at least partly,
responsible for this complication, due to the absence of a
well-defined vascular pedicle enclosing the scaffold.72,73
The same group reported the first use of synthetic scaf­
fold for tracheal repair in 2011. Their patient suffered from
a main bronchus defect after the resection of a recurrent
cancer of the upper airway.74 The authors used a bioartificial
nanocomposite scaffold that they seeded with bone-marrow
derived autologous mononuclear cells (MNCs) in a bioreac­
tor. An asymptomatic, tumor-free outcome was initially
reported. However, in a follow-up Editorial, it appeared that
multiple complications arose.75
Elliott et al also used a decellularized tracheal tube that
was seeded with bone marrow–derived MNCs and autolo­
gous epithelial patches. TGF-beta was added to induce
chondrocyte differentiation. Recombinant erythropoietin
was used to saturate the construct intra-operatively and post­
operatively, to promote angiogenesis.76
Zopf et al used a bioresorbable polycaprolactone-splint
obtained by 3-D rapid prototyping technology to treat a
segmental bronchial collapse. Bronchoscopy demonstrated
a patent airway in expiration after one year follow-up.77
THE CARDIOVASCULAR SYSTEM
In 1919, Guthrie stated that for repairing a blood vessel, “an
implanted segment only needs to temporarily restore mechanical
continuity, serving as a scaffolding bridge for the ingrowth of tissue
from the host.”78 Although tissue engineering-based principles
seem appealing to create the trachea, stability and vascular­
ization of the construct remain the hurdlestones. The defin­
ing characteristics of regenerative cardiovascular implants
have not strayed from that statement, but have taken it one
step further: the tissue-engineered implant not only restores
continuity and serves as a scaffold for tissue migration, it
also has the ability to degrade, leaving remaining neotissue
to integrate in the host.1
VASCULAR GRAFTS
In a NEJM report in 2001, Shin’oka et al described a
tissue-engineering approach to treat occlusion of the right
intermediate pulmonary artery in a 4-year-old patient.79
They used autologous venous-wall cells that were seeded
on a tube composed of poly-caprolactone-polyglycolic-acid,
reinforced with woven PGA. They reported a patent trans­
planted vessel after a 7-month follow-up.
In a multicenter study, McAllister et al reported the use
of a tissue-engineered autologous vascular graft to create a
vascular access for hemodialysis in ten patients in need of
an AV-fistula but without having appropriate veins.80 They
cultivated confluent sheets of autologous fibroblasts and
their deposed extracellular matrix and seeded them around
a stainless steel mandrel. After the vessel was taken off the
mandrel, endothelial cells were seeded into the lumen. The
patency rate was 60% at 6 months, equal to the patency rate
of natural AV-fistulae.
In another clinical protocol, Hibino et al used autologous
bone-marrow mononuclear cells seeded on a biodegradable
scaffold of PGA and ε-caprolactone/L-lactide to create a
cavopulmonary conduit; 5 out of 25 patients developed a

CHAPTER 6 — Tissue Engineering
e33
5. Harrison R, St-Pierre JP, Stevens MM. Tissue engineering and
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6. Fisher MB, Mauck RL. Tissue engineering and regenerative medi­
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Eng 2013;19:1–13.
7. Fuchs JR, Nasseri BA, Vacanti JP. Tissue engineering: a 21st century
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29. Yoder MC, Mead LE, Prater D, et al. Redefining endothelial pro­
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32. Kannan RY, Salacinski HJ, Sales K, et al. The roles of tissue engi­
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We intensively appreciate the importance of vascular
requirements of tissues, the impact of hypoxia and revascu­
larization on repair, the background of a chronic wound
environment, and the role of bacterial clusters and infec­
tion. The reconstructive surgeon values the powerful role
of autologous donor tissues versus the needs for allogenic
tissues and allotransplantation, the induction of tolerance,
and the effect of immunogenicity. For these reasons, we are
perfectly positioned to analyze and investigate, and guide
and lead in the further developments in tissue engineering
and regenerative medicine.
Expert Commentary 
James Chang, MD
Drs Vranckx and Den Hondt, highly regarded experts in tissue
engineering from Belgium, have provided an excellent update
on this exciting topic.
Plastic and reconstructive surgeons continue to face short-
ages of tissue after trauma, tumor resection, and/or congenital
absence. While many areas of medical research have embraced
tissue engineering, it is likely that reconstructive surgery appli-
cations for this strategy will be among the first to reach wide-
spread use.
Tissue engineering is an interdisciplinary scientific field that
combines the principles of life sciences and engineering toward
the development of biological substitutes that will serve to
restore, maintain, or improve tissue function. It is a nascent
field, now evolving to many possible tissues. It has drawn
intense academic and commercial interest because of its trans-
lational (bench-to-bedside) potential.
The critical challenges for applying tissue engineering to
reconstructive microsurgery relate to the cells, the scaffold, and
the ultimate product, the tissue. As the authors have pre-
sented, the field of tissue engineering, and the purpose of all
research papers, can be divided into these three components.
The authors also rightfully focus on the need for vascularization,
decellularization of tissues as scaffolds, and the use of stem
cells to accelerate re-seeding and proliferation.
The ultimate success of tissue engineering will be estab-
lished when the body incorporates the new tissue, and normal
structure and function are again restored. In some tissues such
as bone, the structure is the function. In more complex tissues
such as skeletal muscle, coordination and control of contractile
forces must be re-created.
Tissue engineering has made rapid advances in its short
span. Given the examples in this chapter: skin, urethra and
bladder, bone, trachea, and the cardiovascular system, we are
on the cusp of seeing this research progress translate into
clinical benefits. Other tissue substitutes such as for tendon,
nerve, and cartilage, will likely follow as the science and tech-
nology of tissue engineering reach translation. All of us look
forward to the advances that will give us new tissues with which
to reconstruct our patients.
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print].

28
Percutaneous Aponeurotomy
and Lipofilling (PALF):
A Regenerative Alternative
to the Flap
Roger Karl Khouri Jr  |  Roger K. Khouri
7 
INTRODUCTION
“Don’t cut what you don’t see!” This rule mandates large inci­
sions and wide open surgical exposure to safely dissect apo­
neurotomic fibers and release restrictive scars or fascial
structures.
“Borrow from Peter to pay Paul.” This fundamental principle
of flap reconstruction in plastic surgery creates defects at
the donor site, generates more scars, creates wound healing
issues, and often leads to reconstructions that look like
patchwork.
We have recently developed the percutaneous aponeu­
rotomy and lipofilling (PALF) procedure as the regenera­
tive alternative to the classic open scar releases and flap
transfers (Figs 7.1–7.3). Instead of “borrowing from Peter
to pay Paul,” we developed an incisionless way to release
contractures and induce Paul to regrow and regenerate the
needed tissue himself. PALF is based upon the following
fundamental principles and observations:
1. Needle-pricks in the 1–2 mm range leave no scars (this
is why intravenous lines usually leave no scars). There­
fore, multiple nicks with a 1 mm needle applied in a
Figure 7.1  FLAP vs PALF vs relaxing incisions: Z-plasty flap trans­
position (top) is compared with the PALF procedure (middle) and the
fasciotomy/relaxing incisions (bottom), simulated on a surgical glove
with incisions outlined with a blue marker. (A,B) In the classic Z-plasty
flap transposition, a 5 cm vertical tightness is expanded to 7 cm at
the expense of a horizontal tightness. “Borrowing from Peter to pay
Paul” resulted in no overall tissue gain. Scars were left behind and
flap necrosis and wound healing issues were risked. PALF uses a
series of small percutaneous nicks to mesh the deeper tissues that
restrict advancement. (C,D) Mesh expansion of the restrictive subcu­
taneous tissue enlarges the flap from 8 to 11 cm, while leaving behind
a network of small gaps where fat grafts can survive. A net 3 cm
tissue gain (30%) was generated without new scars. (E,F) In the fas­
ciotomies or relaxing incisions, instead of meshing the tissue with
multiple tiny nicks, two large cuts are made. Advancement of the
tissue is not as even and the cuts expand into large open spaces
where fat grafts would pool with poor interface with the recipient,
leading to fat necrosis, fibrosis, wound healing issues, and likely loss
of the expansion from scar contraction.1
A
B
C
D
E
F
PART 1  —  PRINCIPLES

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
29
4. The body can regenerate missing tissue to bridge gaps in
the 1 mm range, while gaps in the 2 mm range are good
recipients for fat grafts with regenerative abilities.
5. A fine mesh pattern of 1–2 mm gaps is capable of expand­
ing the meshed area by 20–30% (meshing ratio 1 : 1.2).
Meshing the tissues also creates a scaffold matrix for fat
grafts with regenerative potential.
2-D APPLICATION OF PALF
For patients with contractures or localized surface tissue
coverage defects, PALF is an alternative to the classic flap.
It generates the tissue needed for the reconstruction in situ,
without the traditional incision-needing, scar-creating, and
complication-prone flaps.
The crucial component of PALF is strong tension main­
tained in the direction of tissue deficiency throughout the
percutaneous release process. For 2-D hand contractures
defects (Fig. 7.4), we use a strong lead hand retractor that
maintains strong extension force. For other parts of the
body (Fig. 7.5), we use hooks or temporary retention sutures
to maintain tension. We then adhere to the following rules
as we perform the PALF:
1. Since PALF can safely generate only 20–30% tissue gain
over the meshed area, we plan the extent of aponeurot­
omy mesh release based upon the defect size. For
example, to gain 4 cm, plan to release 8–10 cm on each
side of the defect.
2. In order to maintain the tension throughout the release
process, mesh in an orderly fashion from proximal to
distal along the tensed areas. And whenever possible,
restore tension as it dissipates with the meshing.
3. To preserve perfusion and the underlying vascular
network, do not incise and do not undermine.
4. Release tissues evenly along the entire length of the area
placed under tension. It is important to avoid relaxing
incisions or localized areas of over-release. These lead to
cavities where fat grafts will pool and fail to revascularize
for lack of intimate graft-to-recipient interface with a
Figure 7.2  Scalp defect closed with PALF instead of a flap. (A) 4 × 5 cm scalp defect surrounded by scars from previous cancer excisions.
(B) Wound edges approximated under extreme tension with retention sutures over bolster. (C) Percutaneously meshing 8 cm on both sides of
the defect led to a tensionless closure with 5-0 nylon. (D) Uneventful healing 1 week postoperatively.
A
B
C
D
Figure 7.3  (A,B) Palmar wound closed with PALF tissue regenera­
tion instead of flap. Mesh expansion of the native palmar aponeurosis
allowed tensionless closure with 5-0 nylon stitches. Lipofilling the
gaps in the mesh pattern prevented recurrence of the tightness
and helped regenerate the needed tissue. This is the principle of
the recently described modification of the Dupuytren release
technique.2
A
B
staggered pattern can go through the skin without leaving
a permanent scar.
2. Needles only cut fibers under tension; this selective
cutting ability spares nerves and other vital structures
that are not tight when the contracture is forcefully
extended. This then opens the possibility of safely releas­
ing contractures percutaneously without open exposure.
3. Staggered needle-pricks can generate a pattern of slits
that mesh-expand in the direction of the tight traction
in a fashion similar to a meshed skin graft expansion.

30
PART 1 — PRINCIPLES
Figure 7.4  Mid-palmar stellate contracture of
the hand treated with PALF. Gunshot blast
injury allowed to heal by secondary intension.
Despite months of splinting and therapy, the
patient has a mid-palmar stellate scar contrac­
ture and tendon adhesions that restricted
digital extension (A,B). The deficiency was
treated with a PALF similar to a Dupuytren
contracture release.2 With the contracture
under tension, the restrictive scar was mesh-
expanded through multiple punctures and the
resultant loosened structure was grafted with
30 mL of dilute lipoaspirate, diffusely injected
into the palm (C–G). The hand was splinted
in extension for 1 week and then with night
splints for 3 months. Results 6 months post­
operatively are shown (H,I).1
A
B
C
D
E
F
G
H
I

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
31
3-D APPLICATION OF PALF
CICATRIX TO MATRIX
PALF is also applicable to more complex 3-D contour
defects. Whether it is a concave deficiency that needs to be
filled or a convex tissue mound that has to be re-created,
PALF is an incisionless regenerative alternative to tradi­
tional flap transfers. The major application is breast recon­
struction, especially the scarred breasts from radiation or
from previous failed reconstruction attempts.
Whenever possible, we prefer to stretch-expand in 3-D,
the tissue defect prior to the PALF. External expansion of
the recipient site creates more space for grafting, creates
more area to mesh, and prepares the skin envelope to
accept the additional volume without tension. Pre-expansion
also increases capillary density to preserve a functional capil­
lary network, despite more extensive mesh release.
Figure 7.5  Axillary contracture treated with PALF. A 42-year-old male with second- and third-degree burns to the trunk, axilla, and left upper
extremity treated with skin grafts. Despite therapy and extension splints, he presented 1 year later with a severe axillary contracture (A). After
tumescent lipofilling of the burn scar with 150 mL of dilute lipoaspirate, and with the contracture maintained under tension by extending and
abducting the shoulder, a percutaneous aponeurotomy of the restrictive scar was performed through hundreds of staggered skin nicks over
a wide area. To preserve the integrity of the scar and its ability to support fat grafts, the concentration of nicks in the axilla was limited. Tissue
length needed for arm elevation was gained by performing the PALF over an area extending from the antecubital fossa to the abdomen (B).
At 3 months follow-up, a 45° abduction gain was achieved, and the scar was significantly softened (C).
A
B
C
stromal/vascular scaffold. Cavity is the enemy of fat graft­
ing and should be avoided at all cost.
5. As it mesh-expands under tension, percutaneous apo­
neurotomy with the Rigotome® should create a fine hon­
eycomb pattern of tiny, <2 mm cavities. The Rigotome
device holds multiple small needles in place, allowing
multiple percutaneous nicks to be performed at once.
6. Graft about 0.1 mL of dilute lipoaspirate per 1 cm of
reinjection. A 10 cm-long microribbon will contain 1 mL
of lipoaspirate. The fat is injected with a blunt cannula
in a diffuse, spray-like fashion through 3–4 needle punc­
ture entry sites.
7. Whenever possible, splint the PALF area in extension, or
in such a way that maintains open the release without
applying pressure on the PALF area. The splint keeps the
expanded area in the open position and maintains
tension on the expanded area.

32
PART 1 — PRINCIPLES
Figure 7.6  (A,B) A scar is like a restrictive solid brick wall tethering
down the tissues and separating two fatty compartments. Rigottomies
and “Jackhammer grafting” can mesh-expand the brick wall, loosen
the scar, and create openings or microcavities where the graft can
lodge and survive. The cicatrix becomes a matrix for fat grafting. The
result is a scar that is less restrictive, less brick-like, and closer to
normal fat. Repeating the process can altogether eliminate the scar.
A
B
KEYS TO FAT GRAFTING
Fat grafting is a key component of PALF, but it also has its
own benefits for several indications. Patients would much
rather undergo minimally invasive procedures with needles,
cannulas, and syringes than undergo invasive flap surgeries
or be implanted with prosthetics. For decades, patients and
surgeons have wanted to transfer excess fat for reconstruc­
tion. But until recently, the only reliable method was the
invasive, morbidity, and complication-prone flap transfers.
As simple as autologous fat transfer sounds, it presents
unique challenges, which we have only recently discovered
how to overcome. These challenges stem from the fact that
fat grafts are avascular and simple bolus injections will form
necrotic cysts in most conditions. The four major challenges
are listed and discussed below:4–6
1. Surface area-to-volume ratio to ensure vascular inoscula­
tion
2. Interstitial fluid pressure build-up that limits recipient
capacity
3. Recipient site vascularity
4. Ability to differentiate necrotic cysts from cancer
Surface Area-to-Volume Ratio.  Fat grafts receive nutrition
entirely by diffusion for the first three postoperative days,
until revascularization occurs. The rate at which oxygen dif­
fuses into the graft is directly proportional to the surface
area over which oxygen can diffuse. The rate at which the
graft metabolizes oxygen is directly proportional to the
volume of the graft. As the radius of a cylindrical fat injec­
tion increases, its surface area-to-volume ratio decreases.
Therefore, in the central region of a large fat injection, the
tissue is metabolizing oxygen more rapidly than it is receiv­
ing oxygen by diffusion, leading to necrosis. According to
our calculations and our clinical experiences, any injected
fat lobule with a radius >1.6 mm is likely to have a region
of central necrosis.4 In a given volume recipient site, there
is a limit to how many small grafts can be injected before
these small injections begin to coalesce into larger pools.
Therefore, successful large-volume fat grafting to the
breast requires craftsmanship and the ability to “spray-
deliver a mist” in the 3-D recipient site, as small individual
droplets that do not coalesce. Larger blobs delivered as
caulk boluses will not survive as well. Mega-volume fat grafts
require microfat droplets.
Interstitial Fluid Pressure.  In 3-D grafting, the recipient site
enlarges and commensurates with the added graft volume,
but there is a limit to how much the recipient can enlarge
to accommodate that volume increase. This has to do with
the mechanical compliance of the recipient; a factor that is
not constant. Healthy, unscarred recipient subcutaneous
tissue is most compliant and will expand to accept a 20%
volume increase before reaching its compliance limit and
becoming very stiff. Beyond that limit, adding even a small
drop of fat will increase the interstitial tissue pressure (IFP)
to a level that compresses the capillaries, reduces blood
perfusion, and the rate of oxygen delivery to the grafts,
resulting in more necrosis.
Pre-grafting expansion is achieved in the breast with the
Brava® external expander device. Brava is a vacuum-based
bra that applies isotropic mechanical distraction forces to
the breast surface. It was developed to expand breasts pre­
operatively and induce angiogenesis and adipogenesis.3 The
resultant increased volume and mechanical compliance of
the breasts allows the surgeon to spray many more micro­
grafts of fat without coalescence and without significantly
increasing interstitial fluid pressure.4 The added vasculature
increases the total blood flow to the tissue and decreases the
average distance that oxygen must travel to reach the center
of a graft.4 Brava cycles between 60 mmHg for 2 min and
no pressure for 1 min. It is used for 10–12 h/day for 2–3
weeks preoperatively and without interruption for the last
24–48 h, preoperatively. We currently recognize that the
minimum therapeutic dose is 200 h of cycling vacuum dis­
traction of the breast over a 15-day period. It is the intensity
of use that matters. Accumulating 200 h over a longer time
period is much less effective.
After adequate external expansion, we meticulously inject
dilute lipoaspirate in a spray-like fashion through multiple
puncture wound entry sites. The graft is often injected with
the “Jackhammer grafting” technique that helps release
contractures. Unlike grafting a healthy recipient site with
smooth passes that release the fat while the cannula is
retracted, the “Jackhammer” cannula forcefully pokes mul­
tiple tunnels into the cicatrix to loosen it, and injects it with
dilute lipoaspirate, which induces tumescence and places
the restrictive fibrous bands under tension. Remaining
fibrous bands are then released with the “Rigottomy” needle
release. Similar to the 2-D meshing of a skin graft, we use
fine, sharp needles to create many nicks in the contracted
tissue to induce a 3-D release that expands the scar to
increase the volume.
The 3-D Rigottomy of the PALF transforms a restric­
tive cicatrix into a larger recipient matrix with many micro­
cavities that can support the fat grafts through diffusion
until neovascularization occurs. When the microcavities in
a brick-like solid scar get filled with micrografts of fat, the
scar becomes less brick and more like the fat around it.
Repeating the procedure can eliminate the scar and turn it
into fat, as the surrounding soft tissue. The process of serial
Rigottomy and fat grafting effectively transforms the cicatrix
into the recipient matrix scaffold for fat grafts (Fig. 7.6).

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
33
GENERAL FAT GRAFTING TECHNIQUES9,10
FAT HARVEST
For fat harvest we favor fat from deposits that fluctuate less
with body weight. We ask the patient to avoid gaining weight
before the surgery and, if possible, to lose some weight so
the grafts enlarge with return of original weight. In patients
with no localized deposits, we harvest a thin layer over a
large surface. We cannot directly visualize the fat harvested
from the cannula tip, so we employ the “sprinkler system”
of “evenness through randomness.” We use a cannula with
a diameter in the 2 mm range so that we can enter through
needle puncture holes and harvest a few microribbons
along long criss-crossing arcs. These puncture sites require
no suturing and essentially leave no scar, allowing multiple
entry sites. For a typical trochanteric fat harvest site, we use
at least eight entry sites with a 14G hypodermic needle.
To estimate donor site availability, we use the “Palm &
Pinch Test.” The surface area of a surgeon’s palm is about
200 cm2, so if a patient’s anterior thigh has a surface area
of five “Palm Measures” and a depth of 0.25 cm of fat, we
can harvest about 250 mL of fat per thigh. We rarely turn
away patients for lack of fat stores.
According to our experience, fat harvesting is most effi­
cient with a 12-hole cannula at a constant pressure of
300 mmHg K-VAC syringe (Fig. 7.8). This is a handheld,
spring-loaded syringe that provides this constant pressure
along the entire excursion of the plunger due to rolled
ribbon springs, similar to measuring tape coils.
FAT PROCESSING
We use an atraumatic transfer valve (AT-Valve) that trans­
fers the lipoaspirate from the K-VAC syringe to the collec­
tion container without switching syringes and cannulas. It is
a flutter type valve that does not clog with tissue, has a wide
bore, and a low-pressure gradient. It automatically trans­
fers the lipoaspirate harvested in the K-VAC syringe to the
collection bag as the syringe spring is cocked again.
For successful mega-volume fat grafting, we should never
graft beyond the physical capacity of the recipient to accept
the added amount of tissue. We monitor this by measuring
IFP in a fashion similar to compartment pressure measure­
ments (Fig. 7.7).
Recipient Site Vascularity.  Most recipient sites have suffi­
cient vasculature to support their own metabolism but not
enough to support large grafts. The capillary density of the
recipient is a critical factor. The higher the density, the
closer every microfat graft droplet is to a capillary.
Ability to Differentiate Necrotic Cysts from Cancer.  Particu­
larly in the breast, radiologists in the past could not differ­
entiate between necrotic cysts and cancer. However,
technological advances in radiology have made this chal­
lenge obsolete.7
To overcome the first three obstacles of fat grafting, and
generate the live block of tissue required for the reconstruc­
tion, we must create a 3-D, well-vascularized, biocompatible
scaffold that can be seeded with cells and connected to the
endogenous host system. This is the holy grail of tissue
engineering. Researchers have attempted to create scaffolds
with titanium substrates, poly(l-glutamic acid), poly(l-
lysine), and many others. Instead of chemically synthesizing
a scaffold, we have harnessed the regenerative capabilities
of mechanical forces to induce the body to generate its own
3-D, well-vascularized scaffold in situ.
Fat grafting was originally pursued for its ability to add
volume and fill cavities. However, a growing body of evi­
dence suggests that adipose-derived stromal cells (ASCs) in
adipose tissue have great regenerative potential.5 Once they
receive adequate vascular support, ASCs differentiate and
proliferate to regenerate tissues similar to their surround­
ings. Thus, by using mechanical forces along with tiny pricks
that can mesh-expand the tighter structures, we generate
3-D recipient scaffolds. Then, seeding this construct with
adipose tissue, we harness the body’s endogenous regenera­
tive capabilities to tissue engineer reconstruction that would
have classically required flap transfers.1,8
Figure 7.7  Eleven 4 mm yellow droplets can be evenly spread inside a 42 droplet-sized recipient bed without crowding, coalescence, or
increased IFP of the recipient. However, squeezing another 10 droplets results in two problems: (1) confluence as droplets coalesce to become
>4 mm and endup with central necrosis; and (2) an inability of the recipient bed to expand enough to accommodate the additional size increase,
upon which IFP will rise to choke the circulation and cause additional necrosis.
=
=
10
11
42
53
63

34
PART 1 — PRINCIPLES
Figure 7.8  Lipografter™ set up in harvesting mode. A 12G, 12-hole
cannula is connected to the K-VAC spring-loaded syringe via the
AT-Valve. Fat is drawn into the syringe as the plunger is pulled by the
ribbon springs of the K-VAC at a constant 300 mmHg vacuum pres­
sure along its entire excursion. Pushing the plunger back down
re-cocks the ribbon’s springs, and the AT-Valve ensures that the
lipoaspirate is automatically sent to the collecting bag.
Figure 7.9  Paste-like appearance of compacted fat from lipoaspi­
rate centrifuged at 1200g (top), compared with the loose slurry of
lipoaspirate centrifuged at 15g (bottom).
Figure 7.10  14G single-hole spatulated tip grafting cannula con­
nected to a 3 mL grafting syringe via the AT-Valve in grafting mode.
Thanks to the valve, fat can be repeatedly aspirated from the collec­
tion bag into the syringe and automatically injected back through the
cannula into the breast. A small, 3 mL syringe allows precise delivery
of fine micrografts as a mist. The economy of motion by not having
to switch and reload syringes saves operative time.
4. Lipoaspirate contains many beneficial factors such
as plasma, platelets, and growth factors that we prefer
to preserve instead of discarding with stronger
centrifugation.
5. The excess fluid places the restrictive fibers under tension
and allows their selective cutting with needle tips with the
Rigottomy technique. This release is bloodless due to
epinephrine from the tumescent liposuction being
present in dilute lipoaspirate.
FAT DELIVERY
For fat injection, we use a 14G cannula with a single hole
just proximal to the spatulated tip. The distal third is curved
to better follow the contour of the breast, and it is either 15
or 25 cm long, depending on the grafting site. Grafting is
performed with the same syringe and container as harvest­
ing, but with the AT-Valve in reverse mode. Injection sites
are made with a 14G hypodermic needle. The spatulated tip
creates a 0.1 cm2 (2.5 mm × 4 mm) recipient cleft, so each
pass with the 25 cm cannula delivers about 2.5 mL (0.1 mL/
cm of tunnel). This theoretically ensures that no adipocyte
is >1.3 mm from a recipient capillary (Fig. 7.10).
To avoid coalescence and contour deformities, we use
multiple entry sites to inject microribbons of fat as
in­dividual channels carefully inserted in separate plains:
subpectoral, intrapectoral, subglandular, subdermal, and
subcutaneous. Subdermal and subcutaneous are preferred
because they expand most with Brava, and augmenting su­
perficial planes yields more projection than deeper planes.
Intrapectoral injections are ideal in immediate reconstruc­
tion because the restrictive fascia has been removed, and
grafting can be done under direct vision.
A clock-face marking of the breast can be used as a refer­
ence. In the lower half, we fan out multiple radial passes a
few degrees apart, placing the ribbons in subdermal or
The collection container is then centrifuged at 15g
for 2 min, using a hand-cranked centrifuge. Alternatively,
it is allowed to hang for 15–20 min at 1g, normal gravity
sedimentation. After draining the infranatant fluid, the col­
lection container becomes the graft delivery container.
Compared with the 1200 g Coleman fat processing tech­
nique (Fig. 7.9), low-g centrifugation or simple sedimenta­
tion provides several advantages:
1. It is less traumatic to the delicate adipose tissue.
2. The loose lipoaspirate is less likely to clog the thin-bore
grafting cannula.
3. The dilute suspension provides an added margin of
safety against over-grafting, since part of the graft is fluid
that is readily reabsorbed.

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
35
deeper spaces, alternating each plane for odd- or even-
numbered clock-face hours. The upper half is best for the
deepest muscular and submuscular planes because the con­
figuration of the ribs makes it less likely to enter the chest
when driving the cannula caudally (Fig. 7.11).
Intraoperatively, we insert a catheter in the recipient site
and connect it to a pressure transducer to monitor IFP
during grafting. According to our theoretical calculations
and clinical experience, grafting should be stopped when
IFP reaches 8–9 mmHg.4
POSTOPERATIVE SUPPORT
In our clinical experience, postoperative splinting and
support improves fat graft survival and deformity cor­
rection. Immobilizing and maintaining open the graft-
expanded space is important for many reasons:
1. Immobilization is necessary for graft revascularization.
2. After releasing a contracture and grafting the defect, to
prevent recurrence, it is imperative to preserve the
expanded space in an open state by splinting it in exten­
sion until the graft matures.
3. Tension encourages cell growth, even in a Petri dish.11
4. Splinting maintains a water-rich proteinaceous matrix,
which induces adipogenesis.
REVERSE ABDOMINOPLASTY AND
FAT TRANSFER
To salvage secondary cases with poorly defined mammary
folds, capsular contractures, and a less-than-ideal shape, we
use the reverse abdominoplasty and fat transfer (RAFT).
This can recruit a crescent of upper abdominal and lateral
thoracic tissue into the breast to increase autologous tissue
volume, improve the cutaneous envelope for a more natural
shape, and define new inframammary and lateral mammary
folds. The procedure consists of extensive liposuction of the
abdominal apron in order to loosen it, followed by insertion
of a long purse-string suture that grabs the subdermal tissue
at the caudal end of the epigastric crescent. Pulling up on
the suture recruits the crescent into the breast as a reverse
abdominoplasty, and the purse-string effect defines the fold
and mushrooms out the breast. The suture is then sus­
pended to the clavicle through a bone anchor. However, we
now prefer a soft tissue suspension over the pectoralis
muscle that is made tensionless with extensive Rigottomy
and PALF release of the abdominal skin apron. RAFT allows
for significant advancement of the epigastric apron past
the deep muscle layer to add 150–250 mL of abdominal
fat and 5–10 cm of skin into the breast. The resultant scar­
ring allows the tissues to heal in their new position
(Fig. 7.12).
We also found RAFT to be extremely versatile for primary
breast reconstructions, primary augmentations (where
it provides 100–200 mL of additional volume from the
abdomen); for congenital tuberous breasts (where it pro­
vides the necessary lower pole fullness in one procedure);
and for patients undergoing implant removal (where it can
help create a new breast mound).
With the help of Brava, AFT, and RAFT, PALF prevents
a regenerative, incisionless alternative to flaps for many
indications.
Expert Commentary 
Peter Rubin, MD, FACS
In this chapter the authors present a paradigm challenging
concept of percutaneous aponeurotomy and lipofilling
(PALF), as an alternative to flap procedures. Even the ac­
ronym “PALF” is a clever twist on the word flap. Indeed, this
concept turns the traditional paradigms on end.
Traditional approaches to scar contracture release often
involve excision of the scar and adjacent scar band to fully
mobilize the tissue, adhering to the principle of “re-creating
the defect.” The resultant defect can then be treated by
coverage with a local or distant flap, or skin grafting. The
PALF principle, alternatively, dictates that the scarred tissue
itself can be mobilized by up to 20–30% through percutane­
ous release of scar bands. As the authors point out, this is
a very focused approach in which the scar is essentially
meshed internally to allow mobilization in multiple dimen­
sions. The newly meshed tissue matrix is then filled with
lipoaspirate to complete the process. Fat grafting is well
known to soften scars and can assist in tissue healing through
improving vascularization. The authors favor a dilute aspirate
for their procedures.
As the authors show, this concept can be effective in
releasing significant scar contractures. The fact that tissues
have a maximum advancement potential with PALF of
20–30%, mandates a wide area of treatment in order to prop­
erly mobilize tissues for certain defects. The authors use
several enabling technologies in association with percutane­
ous aponeurotic lipofilling. One technology is the use of Brava
external expansion. The authors have championed this tech­
nology as a method of expanding the skin envelope in breast
surgery and improving vascularization prior to fat grafting. In
conjunction with PALF, the authors can treat breasts that are
heavily scarred, especially by radiation injury. The authors
advocate both preoperative and postoperative expansion.
Another innovative enabling technology is the use of a RAFT
suture. RAFT, or “reverse abdominoplasty and fat transfer,”
mobilizes epigastric tissue in to the chest through the use of
a large purse-string suture anchored to the clavicle. Through
a combination of these techniques, very challenging post-
mastectomy breast deformities can be reconstructed.
The authors are to be congratulated for developing a syn­
ergistic portfolio of innovative techniques to advance and
repair tissue in a minimally invasive fashion. These tech­
niques will most certainly have a place in our reconstructive
treatment algorithms.
Access Figures 7.14 and 7.15, as well as
case examples 7.4 and 7.5 online at

REFERENCES
1. Khouri RK, Smit JM, Cardoso E, et al. Percutaneous aponeurotomy
and lipofilling: a regenerative alternative to flap reconstruction?
Plast Reconstr Surg 2013;132(5):1280–90.
2. Hovius SER, Kan JH, Smit X, et al. Extensive percutaneous aponeu­
rotomy and lipografting: a new treatment for Dupuytren disease.
Plast Reconstr Surg 2011;128:221–8.

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
35.e1
Figure 7.14  (A) A 40-year-old woman presented 2 years after
a bilateral mastectomy. She was not interested in having
implants or flap reconstruction. After three Brava + AFT proce­
dures, she regenerated >600 mL per breast and improved her
body contour without any incisions. (B) At 6 months later, she
feels she has gained back her lost breasts; they feel soft, natural,
and have near normal sensation.
A
B
CASE 7.4  Breast Reconstruction with
Brava, and Fat Transfer

35.e2
PART 1 — PRINCIPLES
CASE 7.5  Breast Augmentation with Brava, AFT, and RAFT
Figure 7.15  (A,B,C) A 30-year-old Asian
woman with minimal amounts of available fat
and a tight breast envelope. After Brava expan­
sion, we plan to recruit the crescent of epigas­
tric tissue to supplement a conventional Brava
+ AFT with a RAFT. Initial lateral view after
150 mL of AFT alone (D,E,F). Additional 150 mL
of recruited tissue provided by the RAFT purse
string tied and suspended to the pectoralis
(G,H,I,J). At the 6-month follow-up showing the
final augmentation from Brava + AFT + RAFT
(K,L,M).
A
B
C
D
G
K
L
M
H
I
J
E
F

36
PART 1 — PRINCIPLES
3. Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autolo­
gous fat transfer is a safe and effective breast augmentation alterna­
tive: results of a 6-year, 81-patient, prospective multicenter study.
Plast Reconstr Surg 2012;129:1173–87.
4. Khouri RK Jr, Khouri RR, Lujan-Hernandez JR, et al. Diffusion and
perfusion: the keys to fat grafting. Plast Reconstr Surg Glob Open
2014;2(9):e220.
5. Kato H, Mineda K, Eto H, et al. Degeneration, regeneration, and
cicatrization after fat grafting: dynamic total tissue remodeling
during the first 3 months. Plast Reconstr Surg 2014;133(3):
303e–313e.
6. Khouri RK, Rigotti G, Cardoso E, et al. Mega-volume autologous
fat transfer – Part I: Theory & principles. Plast Reconstr Surg
2014;133(3):550–7.
7. Veber M, Tourasse C, Toussoun G, et al. Radiographic findings
after breast augmentation by autologous fat transfer. Plast Reconstr
Surg 2011;127:1289–99.
8. Khouri RK, Rigotti G, Khouri RK Jr, et al. Tissue-engineered breast
reconstruction with Brava-assisted fat grafting: a 7-year, 488-patient,
multicenter experience. Plast Reconstr Surg 2015;135(3):643–58.
9. Khouri RK, Rigotti G, Cardoso E, et al. Mega-volume autologous
fat transfer – part II: practice & techniques. Plast Reconstr Surg
2014;133(6):1369–77.
10. Khouri RK, Khouri RK Jr, Rigotti G, et al. Aesthetic applications
of Brava-assisted, mega-volume fat grafting to the breasts. A nine-
year, 476-patient, multicenter experience. Plast Reconstr Surg
2014;133(4):796–807.
11. Petermann AT, Pippin J, Durvasula R, et al. Mechanical stretch
induces podocyte hypertrophy in vitro. Kidney Int 2005;67:
157–66.

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
37
Figure 7.11  (A,B) A 49-year-old woman, 1 year following a right mastectomy and recent positive BRCA diagnosis, presents for recon­
struction of her right breast and a prophylactic mastectomy with immediate reconstruction to her left breast. (C) Prior to the left mastectomy,
she used Brava for 3 weeks to regenerate a recipient scaffold over the right mastectomy defect. Markings for the caudal extent of the
RAFT under the expanded right mastectomy defect and marking for the left skin-sparing prophylactic mastectomy are shown. (D) Defect
after left mastectomy. (E) Immediately after the mastectomy, we grafted the exposed left pectoralis muscle and the Brava-expanded right
mastectomy. Pulling on the RAFT purse-string suture inserted along the inframammary fold mushroomed up a breast mound. (F,G) Third
postoperative day: grafting + RAFT brought fullness to the upper pole of the left defect and generated a breast mound on the right. (H,I)
At 6 weeks later, she resumed Brava expansion to both breasts for 3 weeks in preparation for a second AFT. (J,K) At 6 months following
the second grafting session, she regenerated breasts with near normal light-touch sensation over her reconstructed nipples.
B
C
D
E
F
G
H
I
J
K
A
J
CASE 7.1  Breast Reconstruction with Brava, RAFT, and Fat Grafting

38
PART 1 — PRINCIPLES
CASE 7.2  Breast Reconstruction with Brava, RAFT, and Fat Grafting
Figure 7.12  (A,B) A 55-year-old woman, 1 year after a left mastectomy reconstruction with expanders and an 800 mL implant. She has
poor projection and definition of the breast mound. (C) We extensively liposuctioned fat from the abdominal apron and after removal of
the implants, the breast mound envelope is thin but flaccid. (D) Restoration of fullness requires selective release of the vertical fibers
placed under tension by tumescent lipofilling and Rigottomies while preserving the loose horizontal fibers that provide perfusion. (E)
Diagram illustrating how point B over the epigastrium is advanced by the reverse abdominoplasty maneuver to become the new inframa­
mmary fold, while the old fold is recruited into the breast. The additional cutaneous envelope provides for an improvement in the breast
contour. However, in patients with large initial implants, a smaller implant is needed because maximal inflation of the thin envelope fails
to achieve central mound projection. (F) Result after fat grafting alone. (G) We then inserted the purse-string suture to grab the subdermal
tissue at the caudal end of the epigastric crescent, and pulling on the suture led to a 7 cm reverse abdominoplasty advancement. Sus­
pending the string to the clavicle through a bone anchor creates a new breast mound that still lacks fullness and projection. (H) A 360 mL
implant is then inserted to add fullness. (I,J) At 6 months later, the breast has a much more natural look and feel with better padding to
camouflage the implant and more defined mammary folds.
A
B
C
D
E
F
G
H
I
J
A1
A
B
B1

CHAPTER 7 — PERCUTANEOUS APONEUROTOMY AND LIPOFILLING (PALF)
39
Figure 7.13  (A) A 35-year-old woman with contracted implants for aesthetic augmentation. We removed both right and left implants,
while extensively liposuctioning fat from the apron. Once the implants were removed, the breasts were flaccid (B). We grafted fat into the
breasts and inserted a RAFT suture to grab the subdermal tissue at the caudal end of the epigastric crescent. Tightening the string and
suspending it to the pectoralis creates a new breast mound (C). At 6 months later, without implants, the breasts have about the same
volume with a much more natural look and feel (D).
A
B
C
D
CASE 7.3  Breast Augmentations Using RAFT

40
Lymphedema:
Microsurgical
Reconstruction
Joseph H. Dayan  |  Jaume Masia Ayala  |  Isao Koshima
8 
INTRODUCTION
Up until recently, lymphedema has largely remained on
the sidelines of microsurgery. For many years, most micro­
surgeons avoided lymphatic reconstruction because of
inconsistent results, lack of published data, and concerns
regarding safety in a poorly understood disease process.
Fortunately, the anecdotal era in lymphatic surgery is giving
way to prospective studies and greater integration of our
expanding knowledge of pathophysiology, imaging, and
patient selection, into clinical practice. Advances in basic
science, lymphatic imaging, and more sophisticated surgical
techniques have resulted in a swell of interest in lymphatic
surgery, which is now common in many academic centers.
While there are currently still more questions than answers
in lymphedema, we explore here some of the most popular
techniques in lymphatic surgery as well as the latest insights
into patient selection and operative approach.
LYMPHATIC ANATOMY
AND PHYSIOLOGY
Revisiting the anatomy and physiology of the lymphatic
system is useful, not only for lymphatic surgery, but also
for other cosmetic and reconstructive procedures where
increased awareness of this vast organ system may reduce
the risk of injury to it. The lymphatic system is present
throughout most of the body, although interestingly, it is not
found in certain areas such as the central nervous system,
or cartilage and bones. The lymphatic system as a whole
serves three functions: fluid balance; transporting fats and
fat-soluble vitamins from the gut to the circulation; and
defending against microorganisms as well as tumor cells. As
blood is pumped through the tissues and passes through the
capillary network, most of the fluid that enters the intersti­
tium returns through the venous system. The fluid waste
that remains is removed by the lymphatics that can accom­
modate macromolecules that are too large to enter capillary
venules, which have limited pore size.1 This is the basis for
such studies as lymphoscintigraphy, that depend on prefer­
ential uptake of technetium sulfur colloid into the lymphat­
ics because this agent is too large to fit through the limited
pore size of a venule.
Lymphatic vessels also transport antigen and inorganic
matter (such as silicone, noted in ruptured implants), via
afferent vessels that enter the lymph node on its convex
surface. Both B-cell and T-cell populations are located
within the lymph node, where a coordinated adaptive
immune response occurs following exposure to antigen via
antigen presenting cells.2 Naive lymphocytes become
activated and mature lymphocytes subsequently circulate
through both the blood and lymph seeking out target
antigen, re-entering the lymph node via high endothelial
venules.3 The interconnections between the lymphatic
sinuses and venules are the basis for Cheng’s proposed
mechanism for lymph node transfer.4 After percolating
through the lymph node, lymph exits through the efferent
duct at the hilum where the feeding artery and vein perfuse
the node.
The transport of lymph through this system of vessels and
nodes is interesting, as there is no heart to pump fluid
through this one-way street, which parallels the circulation
of blood. Lymph is propelled independently by intrinsic
smooth muscle contraction within the wall of the lymphatic
vessels that is aided by unidirectional valves.5 Extrinsic skel­
etal muscle contraction also squeezes the lymphatic vessels,
further facilitating lymph transit. This phenomenon is the
underlying mechanism of action for short-stretch compres­
sion wraps that provide a firm surface against which muscle
flexion augments lymph transport.
While intestinal lymph is not typically a focus in plastic
surgery, it plays a role in certain types of primary lymph­
edema and is a significant component of lymphatic physiol­
ogy. Lymphatics in the small intestine are referred to as
lacteals, which absorb fats from the intestinal lumen that
accumulate to produce the milky-appearing chyle.1 This
lymphatic efflux of fats empties into the cisterna chyli,
which is a dilated lymphatic sac that is situated in front of
the L1–L2 vertebral bodies. This structure gives rise to the
thoracic duct, which drains the majority of the body with
the exception of the right upper limb, chest, and head and
neck regions, which are drained by the right lymphatic duct.
The thoracic duct and right lymphatic duct both terminate
in large lymphovenous connections at the junction of the
internal jugular vein and subclavian veins (Fig. 8.1). There
is, however, significant variability in this anatomy, and major
lymphatic ducts can coalesce more superiorly on the inter­
nal jugular vein in the region of the supraclavicular lymph
PART 1  —  PRINCIPLES

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
41
Figure 8.1  Lymphatic anatomy of the head and neck region. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights
Reserved.)
Superficial parotid nodes
(deep parotid nodes
deep to and within
parotid gland)
Subparotid node
Facial nodes
Nasolabial
Buccinator
Mandibular
nodes
Submental
nodes
Suprahyoid node
Superior deep lateral cervical
(internal jugular) nodes
Superior thyroid nodes
Juguloomohyoid node
Anterior deep cervical
(pretracheal and thyroid) nodes
(deep to infrahyoid muscles)
Anterior superficial cervical
nodes (anterior jugular nodes)
Jugular trunk
Supraclavicular nodes*
Subclavian trunk and node
*The supraclavicular group of nodes (also
known as the lower deep cervical group),
especially on the left, are also sometimes
referred to as the signal or sentinel lymph
nodes of Virchow or Troisier, especially when
sufficiently enlarged and palpable. These
nodes (or a single node) are so termed because
they may be the first recognized presumptive
evidence of malignant disease in the viscera.
Occipital nodes
Mastoid nodes
Sternocleidomastoid
nodes
Superior lateral
superficial cervical
(external jugular)
node
Jugulodigastric node
Posterior lateral
superficial cervical
(spinal accessory)
nodes
Intercalated node
Inferior deep
lateral cervical
(scalene) node
Thoracic duct
Transverse
cervical
chain of
nodes
Submandibular
nodes

42
PART 1 — PRINCIPLES
nodes. This point is important to note when harvesting a
supraclavicular lymph node flap where these structures may
be encountered. One might ask, “What would happen if the
thoracic duct were ligated?” It is interesting to note that
ligation of the thoracic duct is the treatment of choice for
refractory chylothorax complicating esophagectomy or
other thoracic intervention, yet lymphedema is typically not
observed following this procedure.6,7 There has only been
one report in the literature of lymphedema from the chest
to the toes following thoracic duct ligation for idiopathic
chylothorax.8 However, it is unclear whether or not there
was a component of preexisting primary lymphedema.
Detailed lymphatic anatomy and drainage of the upper
and lower limbs is still an area of continued exploration.
However, both cadaveric dissections and indocyanine green
lymphangiography (IGL) are providing a more complete
picture of the lymphatic system. In the extremities there is
a horizontal latticework of lymphatic capillaries in the
dermis that drain into “pre-collectors,” which dive deep and
empty into superficial lymphatic “collectors” located in the
subcutaneous layer.9–11 These collectors are easily visualized
on IGL and are long vessels mostly along the medial limb,
which empty into the local lymph node basin. There are also
less numerous lymphatic vessels that are located deep to the
deep muscle fascia that travel alongside arteries. The exis­
tence of connections between the superficial and deep lym­
phatic system is still the subject of further investigation.10,12
The interaction between the superficial and deep system is
a matter of great interest and affects our conceptual frame­
work regarding the role of lymphovenous bypass.13–16
In the lower limb there are lymphatic vessels that travel
along the lesser saphenous vein in the posterior leg, which
enter the popliteal nodes, but the majority of lymphatic
vessels gather around the vicinity of the greater saphenous
vein. These collectors continue up the medial thigh, where
they encounter one or two sentinel lymph nodes located
deep, along the femoral vessels typically several centimeters
below the groin crease (Fig. 8.2).17 These lymph nodes also
receive efferent lymphatic vessels from superolaterally
oriented lymph nodes that drain the lower abdomen and
hips, as well as medially from the superficial layers of the
genitalia. Lymphatic traffic then continues medially (medial
to the superficial inferior epigastric vein) and deep, along
the iliac vessels and ultimately into the thoracic duct. One
question previously posed by Tourani and colleagues, was
How deep are the superficial collectors?12 In the medial
thigh, where the greater saphenous vein is located deep to
the superficial fascial system (analogous to Scarpa’s fascia),
the lymphatic collectors were found both superficial and
deep to this fascia. This may suggest that even superficial
excision of fat in the medial thigh could potentially com­
promise lymphatic drainage although this has not been for­
mally studied.
Lymphatic drainage of the upper extremity follows a
similar motif: most of the superficial lymphatic flow follows
the course of the superficial veins and is ultimately funneled
into a single large sentinel lymph node in the axilla
(Fig. 8.3).9,18 Lymphatic drainage then proceeds more prox­
imally into several other smaller lymph nodes. Based on
intraoperative study using reverse lymphatic mapping,
lymph nodes draining the upper limb are consistently
located high in the axilla in proximity to the axillary vein,
deep to the pectoralis major muscle, and can also contribute
to drainage of the chest.19 These critical lymph nodes can
be supplied by the thoracodorsal artery, lateral thoracic
artery, or direct branches from the axillary artery (Fig. 12.2).
Alternate lymphatic pathways also exist in the upper limb as
lymphatics along the cephalic vein can bypass the axillary
nodes and pass through the supraclavicular lymph nodes.
An interesting cadaveric study by Suami et al., of a patient
who underwent axillary node dissection without clinical
lymphedema, illustrates some key differences in normal and
abnormal lymphatic drainage.10 On the affected side, there
were incompetent lymphatic valves in the pre-collectors with
dermal reflux, and hypertrophy of epitrochlear nodes
around the elbow. The superficial lymphatics were obliter­
ated above the elbow but there was a connection between
the superficial and deep system that allowed drainage to a
few remaining axillary nodes. These detailed anatomic
studies and reports are steadily accumulating into a critical
body of knowledge for further refinement of lymphatic
techniques in the future.
PATHOPHYSIOLOGY
Lymphedema has traditionally been thought of as swelling
resulting from lymphatic obstruction, but we have come a
long way from this concept. Lymphedema most commonly
has a delayed presentation following lymphadenectomy,
and exhibits behavior of a proliferative disease, as opposed
to a simple surgically induced obstruction to lymphatic flow.
While the initial insult to the lymphatic system does cause
lymphatic impairment and edema, an immune response
may ensue, leading not only to destruction of lymphatic
vessels but also fat hypertrophy and fibrosis.20–27 Central to
understanding the progression of lymphedema is the
concept that an initially fluid-filled limb progresses into
a fibrofatty limb that directly affects surgical decision mak-
ing and managing patient expectations. This cascade
of events is also the subject of investigation into medical
therapies that may blunt or reverse this process and could
potentially be used as adjuvant therapies to surgery in the
future.21,23
INDICATIONS FOR LYMPHATIC SURGERY
Awareness of the spectrum of disease in lymphedema from
a fluid-dominant limb to a fibrofatty-dominant limb is
important in selecting an appropriate operation for the
individual patient. There are two general types of surgery
for lymphedema: debulking and physiologic procedures.
Debulking techniques do not treat the underlying cause of
lymphedema, but are aimed solely at reducing limb volume,
essentially treating the fat hypertrophy component of
lymphedema. On the other hand, physiologic procedures
such as lymphovenous anastomosis (LVA) or vascularized
lymph node transfer (VLNT) are aimed at addressing the
underlying lymphatic disease process. While these modali­
ties have been effective at reducing the fluid component of
lymphedema, the effect on fat hypertrophy has yet to be
determined. It also seems that the very best candidates for
physiologic procedures are thin patients that have earlier

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
43
Figure 8.2  Lymphatic anatomy of the lower extremity. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
Great
saphenous vein
Superficial
lymph vessels
Great
saphenous vein
Deep
fascia
of leg
(crural
fascia)
Fascia
lata
Cribriform
fascia
within
saphenous
opening
Horizontal group:
Superolateral
nodes
Superomedial
nodes
Vertical group:
Inferior nodes
Popliteal vein
Popliteal
lymph nodes
Small
saphenous vein
External iliac
lymph nodes
Femoral nerve
Inguinal ligament
(Poupart’s)
Ductus (vas) deferens
Femoral sheath
Femoral canal
(opened)
Femoral artery
and vein
Femoral ring
Lacunar
ligament
(Gimbernat’s)
Deep inguinal
lymph nodes
Great saphenous vein
Superficial
inguinal
nodes

44
PART 1 — PRINCIPLES
pressing the thumb into the patient’s limb for 1 min at
maximal pressure.28–34 If this patient is 100% compliant and
is willing to wear lifelong compression, sustained volume
reduction has been demonstrated over the long term.28
However, many patients are unable or unwilling to wear
constant compression, and do not present with an advanced
fibrofatty limb. These fluid-dominant patients may not be
good candidates for debulking procedures and this is where
physiologic procedures such as LVA and VLNT have played
a significant role. There is a host of different microsurgical
procedures that have had reported successes, including
forms of lymphedema with some lymphatic function still
intact.
There is a role for all of these procedures, but to provide
some context, the goals of the patient and stage of disease
become important. A patient with elephantiasis and irre­
versible skin changes facing potential amputation may be a
candidate for a more radical excisional procedure such as
the Charles procedure, or one of its more recent iterations.
Liposuction is most appropriate for a patient with late-stage
lymphedema and a mostly fatty limb confirmed by Brorson’s
guidelines: less than a few millimeters of pitting edema after
Figure 8.3  Lymphatic anatomy of the upper body. (Reprinted from Netter Anatomy Illustration Collection. ©Elsevier Inc. All Rights Reserved.)
External
mammary
lymph
node group
Lateral
thoracic
vessels
Intercostal
vessels
Internal
thoracic
(mammary)
vessels and
lymphatics
Azygos v.
Thoracic
duct
Superficial
lymphatic
communication
across midline
Lymphatic communication
to subdiaphragmatic areas
Superficial
lymphatics
of breast
Subareolar
lymphatic
plexus
Main
lymphatic
collecting
trunks
Areolar
venous
plexus
Superficial
vv. of breast
and thorax
Pectoralis
major m.
Internal jugular
lymphatic trunk
Thoracic
duct
Superficial venous
communication
across midline
Anterior
mediastinal
lymphatic trunk
Internal mammary
lymphatic trunk
Confluence of
lymphatic trunks
Thoraco-
dorsal
vessels
Central lymph
node group
Subclavian
lymphatic trunks
Interpectoral (Rotter)
lymph node group
Transverse
cervical
lymphatic trunk

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
45
component to their lymphedema evidenced by pitting
edema and a good response to compression and elevation,
they may be considered for a physiologic procedure. If they
have more advanced lymphedema with a mostly fatty limb
with no pitting, and are 100% compliant with compression,
liposuction may be the best option. Of course there are gray
areas with a mixed picture that may benefit from a combina­
tion of liposuction and either LVA or VLNT, although the
timing of these procedures is still a matter of debate.
On the first visit, every patient should be informed of the
risks of VLNT including no improvement, worsening
lymphedema, or donor site lymphedema. Donor site lymph­
edema has been reported, but the quantitative risk of this
serious morbidity is unclear because these reports were of
VLNT without reverse lymphatic mapping, which has
improved the safety of this technique.41–45 In our current
series of 70 lymph node transfers over the past 5 years, we
have not observed donor site lymphedema using the reverse
lymphatic mapping (RLM) technique, although we need
another 5 years and many more cases to better quantify this
risk.19
Finally, while VLNT has a clearly established role in sec­
ondary lymphedema following oncologic treatment, its use
in primary lymphedema is less clear-cut. This is because
there is a spectrum of disease within the category of primary
lymphedema, with a variety of congenital abnormalities that
may all lead to swelling. In our early experience, results were
mixed. Becker has suggested that patients with abundant
hyperplasic lymphatic vessels seen on magnetic resonance
lymphangiography (MRL) could potentially benefit from
VLNT, while those with lymphatic vessel hypoplasia are
generally avoided, although this is anecdotal observation
(Corinne Becker, pers. comm., December 2014). When
starting a lymphatic surgery program, there is a greater
comfort zone in focusing on cancer-related lymphedema. If
a lymph node transfer is considered in primary lymph­
edema, both four-limb lymphoscintigraphy and IGL are
performed to rule out occult impaired lymphatic function
near potential donor sites to minimize the risk of causing
lymphedema in a patient with an already abnormal lym­
phatic system.
After discussing risks and benefits, the patient often
decides if the risk of surgery outweighs the risk of natural
progression of disease. This rules out patients who are on
the fence; the best patient is one that is highly motivated
for surgery and is not second-guessing their decision. If a
patient is interested in surgery, the next step is referral to a
certified lymphedema therapist and performing a thorough
imaging work-up. Preoperative coordination with a lymph­
edema therapist is important in ensuring the limb is in
optimal condition to promote lymphangiogenesis and to
have a seamless postoperative physiotherapy regimen.
Because we are dealing with a poorly understood disease
and the role of lymphatic surgery is still evolving, our incli­
nation is to study the patient with as many tools at our dis­
posal as possible, in order to see patterns in disease and
hopefully some day predict which of these patterns best
responds to a given treatment. This work-up includes mag­
netic resonance angiography (MRA) of potential donor
sites and recipient site; magnetic resonance lymphangiogra­
phy (MRL) of the affected limb; four-limb lymphoscintigra­
phy and IGL; perometer for limb volume or an equivalent
lympholymphatic anastomosis and lymph node-venous
anastomosis. Two approaches that have gained most trac­
tion in the microsurgical community have been lym­
phaticovenular anastomosis and vascularized lymph node
transplantation, which will be the focus of this review. This
brief passage is in no way meant to exclude other viable
procedures, only to highlight a handful of techniques that
have become of recent interest and have demonstrated
promising results.
CONTRAINDICATIONS TO
PHYSIOLOGIC PROCEDURES
There are many patients who will call the office for lymph­
edema or swelling of the limbs from one cause or another
and it is worthwhile knowing in advance which patients will
not be candidates for surgery, particularly physiologic pro­
cedures. The two main contraindications we encounter is
significant venous disease and obesity. Because a lymph
node transfer or LVA relies on lymphovenous shunting, any
venous hypertension may compromise this pressure gradi­
ent and result in a failed operation. Venous insufficiency is
also a very common cause of lower extremity swelling, and
treating the venous disease may alleviate some of the swell­
ing. A history of deep vein thrombosis in the affected limb,
varicosities, and prior vein surgery are relative contraindica­
tions to VLNT or LVA in our practice.
Obesity is another relative contraindication for physio­
logic lymphatic procedures. Elevated BMI has been shown
to impair lymphatic clearance and worsen lymphedema,
and is reported to be a risk factor in developing post-
mastectomy lymphedema.35–40 If a patient were to consider
VLNT, obesity may not only compromise efficacy but may
also increase the risk for donor site lymphedema and throm­
boembolic complications. For these reasons, we recom­
mend weight loss to all patients until their BMI is ≤30 before
offering physiologic lymphatic surgery.
THE INITIAL PATIENT VISIT
The initial visit focuses on evaluating the patient’s type of
lymphedema, their goals, and determining whether a physi­
ologic, debulking, or excisional procedure is appropriate. A
focused history includes the status of the venous system,
history of deep vein thrombosis or pulmonary embolus,
duration of lymphedema, current compression regimen (as
a baseline for postoperative comparison), history of celluli­
tis, radiation, and cancer history. Physical exam includes
inspection of the site of the previous cancer to assess for
recurrence, and inspection of groin, axillary, and cervical
lymph nodes to ensure these potential donor sites do not
have pathology. Exam of the affected limb for fibrosis and
the presence of pitting quickly provides information about
whether the limb is mostly fluid-filled or is already in the
advanced stages of fat hypertrophy and fibrosis. Evidence of
varicosities, and hemosiderin staining suggest venous disease
and may exclude the patient from LVA or VLNT.
On a typical visit, the patient is first evaluated for the pos­
sibility of being a candidate for a physiologic procedure
such as VLNT or LVA. If the patient has a significant fluid

46
PART 1 — PRINCIPLES
axillary vein and its adjacent lymph nodes would likely be a
safer and more effective choice. If both sides are equivalent,
then the side contralateral to the limb with lymphedema is
selected, as this is the preference of most lymphedema ther­
apists. This theoretically allows for clearance of the lymph
from the affected limb to adjacent lymph node basins,
which would preferably not be harvested.
method; limb impedance measurements; elastometer mea­
surements; and standardized photographs. This list of
studies is generally not feasible in many centers, but the
most important ones involve some form of MR imaging, and
physiologic evaluation of the lymphatic system using lym­
phoscintigraphy and/or IGL. Interpretation of this work-up
involves its own learning curve and close collaboration with
nuclear medicine and radiology.
ANATOMIC IMAGING
Radiographic imaging includes magnetic resonance angiog­
raphy (MRA) of both the recipient and potential donor
sites. Ablavar contrast, as opposed to gadolinium, is used
and stays in the blood for a longer period of time yielding
higher resolution. The thin-cut venous phase is used for
review. For the recipient site, the fluid versus fat component
as well as limb volume can be calculated (Fig. 8.4). Occult
recurrence and severe stenosis of the axillary, femoral, or
iliac veins following surgery and radiotherapy can also be
visualized. If present, venography can better characterize
the nature of vein stenosis. We have seen a number of
patients with axillary node dissection and radiation with
severe axillary vein stenosis requiring extensive lysis to dilate
the vein and one patient who required axillary vein recon­
struction. As stated earlier, venous hypertension can be a
component of limb swelling and could compromise the
VLNT or LVA. MRA of the recipient site is performed 1 year
postoperatively to confirm viability and quantity of lymph
nodes successfully transferred.
MRA of the donor sites allows the surgeon to select the side
with the most favorable lymph nodes and vascular anatomy
(Fig. 8.5). This is the side with the largest number and size
of lymph nodes, positioned farthest away from the lymph
nodes that drain the adjacent extremity.17 For example, if
performing an axillary lymph node transfer, the side with
the most abundant lymph nodes located farthest from the
Figure 8.4  (A) MRA of the leg, coronal section. Lymphedema of the left leg in a patient with a significant fluid component (black = fluid). (B)
Lymphedema of the left leg in a different patient with pronounced fat hypertrophy and a relatively smaller fluid component. These patients may
respond differently to LVA or VLNT in terms of volume reduction.
A
B
Figure 8.5  MRA of the pelvis, coronal section illustrating location of
the target lymph nodes (green arrows) and the sentinel lymph nodes
draining the lower limbs (red arrows). U, umbilicus; GC, groin crease;
Sar, sartorius; Yellow arrow, distal superficial circumflex iliac vein.

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
47
at detecting impaired lymphatic function compared with
lymphoscintigraphy.
In Koshima’s group, preoperative IGL is used to deter­
mine if a patient is likely to respond to LVA (and may also
relate to their response with a VLNT).14,46–48 On a histologic
level, early-stage lymphedema begins with dilation of
obstructed lymphatic vessels, followed by vessel contraction,
and ultimately sclerosis. Koshima et al. observed that preop­
erative IGL findings demonstrating a “linear” pattern with
functioning lymphatic vessels correlate with dilated lym­
phatics intraoperatively, while more advanced findings of
dermal reflux on IGL correlate with sclerosed lymphatics.
The best outcomes in their experience were in patients with
early stage lymphedema, while those with the most advanced
level of dermal reflux (“diffuse” pattern) are now seen as
poor candidates (Fig. 8.6). Lymph node transplantation is
considered in this subset of patients.
Masia contends that sclerosed lymphatics have long lost
their smooth muscle peristaltic function, which may render
both LVA and VLNT ineffective. There is still discussion as
to whether or not passive forces may allow these physiologic
procedures to work in LVA and VLNT in the more advanced
stages of lymphedema. It seems to be a trend now that
earlier intervention, even with VLNT, may lead to a more
favorable result. Finally, Chang’s experience with LVA has
shown best success with upper extremity lymphedema as
opposed to the lower extremity.49–51
In summary, MRA demonstrates the fluid-to-fat ratio very
clearly and we can explain more precisely what to expect in
terms of volume reduction if the fluid component of the
limb is mostly reduced by a physiologic procedure. For
example, if 50% of the limb is fat hypertrophy, this patient
will never have normalization in limb size with a physiologic
procedure alone, and their expectations can be tailored to
their scan results. Lymphoscintigraphy and IGL provide a
physiologic assessment, and while there are few data to go
by at this time, it appears that earlier stage lymphedema with
some form of functional lymphatics may respond more
favorably to LVA or VLNT. Late stage fat-hypertrophied
limbs with no pitting may not respond well and may be
better served with liposuction provided constant compres­
sion is something the patient will adhere to. Combinations
of these two procedures are still being explored at this time.
If the patient is a candidate for LVA or VLNT, it is generally
in the realm of surgeon preference in terms of which
Magnetic resonance lymphangiography (MRL), though
not yet widely available, is being increasingly explored, as it
can reveal a more complete picture of the lymphatic system
and has become Becker’s central mode of work-up. Neligan
uses MRL to detect the presence of discreet lymphatic
vessels. If there are identifiable lymphatic vessels present, he
will perform an LVA, if not, the patient is offered a lymph
node transfer.
FUNCTIONAL IMAGING
LYMPHOSCINTIGRAPHY
We routinely perform a standardized four-limb lymphoscin­
tigraphy to provide a baseline for both donor and recipient
sites. This allows us to determine whether or not the patient
has a complete versus partial obstruction, and if complete,
what level of obstruction. Ming-Huei Cheng will go straight
to performing a VLNT if a complete obstruction is visual­
ized on lymphoscintigraphy. If partial obstruction is visual­
ized, the patient is referred to lymphedema therapy for a
trial of conservative treatment (Ming-Huei Cheng, pers.
comm., January 2015). This may also determine where to
place the lymph nodes in the future, although this is cur­
rently under study. One question we are asking is, if the
patient has a complete obstruction at the level of the elbow,
should we be placing the lymph nodes distally in the wrist
or forearm as opposed to the axilla? Comprehensive imaging
evaluation and prospective study will answer many of the
questions this chapter may prompt. One-year postoperative
four-limb lymphoscintigraphy is used to assess both the
recipient site and determine if there is any subclinical
impaired lymphatic transport at the donor site.
INDOCYANINE GREEN LYMPHANGIOGRAPHY
Indocyanine green lymphangiography (IGL) provides the
most detailed view of the superficial lymphatics and allows
the surgeon to evaluate lymphatic pumping function. The
only limitation is that lymphatics deeper than 5 or 10 mm
cannot be visualized with current technology, in compari­
son with lymphoscintigraphy, which provides a view of the
entire lymphatic system but at a much lower resolution,
limited to only major lymphatic collectors. All of our
patients receive a four-limb IGL preoperatively and at 1
year postoperatively for comparison and evaluation of the
recipient and donor sites. IGL appears to be more sensitive
Figure 8.6  (A) Indocyanine green lymphangiography (IGL) in a lymphedema patient with some dermal backflow but a single functional lym­
phatic vessel. Potential candidate for LVA. (B) IGL of a patient with advanced lymphedema and diffuse dermal backflow.
A
B

48
PART 1 — PRINCIPLES
IGL in identifying lymphatics and progress in supermicro­
surgical technique and instrumentation. Indocyanine green
lymphangiography involves intradermal injection of 0.1 mL
of dye into the web spaces of the affected extremity. Using
a near-infrared detector, the superficial lymphatics can be
visualized and used to map out intact lymphatic vessels.
Dark areas, which cross the lymphatics are typically veins
that Chang uses as a guide to determine where to make the
incisions. Koshima’s group uses a device that detects veins
in addition to IGL to plan the incisions in areas where veins
and lymphatics are in close proximity.47 Previous strategies
involved injecting blue dye intradermally but the dye cannot
be visualized deeply through the skin, and in more advanced
cases, is not always taken up by the lymphatics. However,
patent blue or Lymphazurin dye is still commonly injected
distal to the planned incision to facilitate identification of
lymphatic vessels and confirm patency of the anastomosis.
The location and number of incisions is still a subject of
controversy. Koshima’s group advocates as many anastomo­
ses as possible, pointing out that their results correlate
directly with number of bypasses.13,46,48,57–63 Others such as
Chang, limit the number of anastomoses to only a few at
most, with the incision placed at the most proximal terminal
end of the visualized patent lymphatic vessel.50 He will also
avoid a major lymphatic collector if it is traversing the entire
limb and entering the proximal lymph node basin in a
patient with a partial lymphatic obstruction. The concern is
that dividing a lymphatic in continuity that is contributing
to drainage of the affected limb may actually worsen the
lymphedema, although no reports of this have yet surfaced
in the literature.
Based on the patient’s anatomy and IGL findings, a
series of 2 cm transverse incisions are planned along
the medial aspect of the extremity; 1% lidocaine with
1 : 100 000 epinephrine is injected into these markings
and the entire procedure can be performed under local
anesthesia if desired. The incision and dissection are
performed under a high-powered microscope (at greater
magnification than an average operating microscope pro­
vides) where the target lymphatic vessel(s) and neighboring
vein(s) are identified in the subcutaneous layer using super­
fine instruments.
At this point, a decision is made regarding the various
potential anastomotic combinations that can be performed.
The goal is to allow for a favorable pressure gradient from
the lymphatic system flowing into the venous system. When
the vein is divided, ideally there should be minimal to no
back bleeding, as excess venous back pressure would prevent
lymph from flowing into the vein. The lymphatic vessel does
not need to be clamped, but if there is some venous back
bleeding, a microvascular clamp is placed proximally on
the vein.
The anastomotic arrangement depends on the number
and size of the lymphatics and veins. Koshima has previously
illustrated a number of arrangements, the most convenient
of which is a lymphatic vessel in proximity to a bifurcated
vein.57,59–63 The lymphatic is divided and both the proximal
and distal ends are anastomosed to each vein branch, allow­
ing for antegrade venous outflow. If such a configuration is
not possible, the second best scenario is a side-to-end
arrangement. A window is cut into the sidewall of a lym­
phatic using a microscissor, and this aperture is then
procedure to proceed with. Nonetheless, these imaging
studies provide useful information for both patient and
surgeon and may present us with keys to improved patient
selection in the future.
LYMPHATICOVENULAR ANASTOMOSIS
VERSUS VASCULARIZED LYMPH
NODE TRANSFER
Most microsurgeons are now exploring both LVA and VLNT
and even combining these techniques – a sign that no single
approach has been completely satisfactory. Unfortunately,
there are no data comparing these two techniques. One of
the major hurdles is that outcomes are difficult to assess in
lymphedema. Limb volume or circumference has domi­
nated outcome measures, yet can be easily manipulated
postoperatively by aggressive compression and physiother­
apy. This has led to skepticism and a broad spectrum of
opinion on surgical management.
While there is currently no consensus on which proce­
dure is most appropriate for a given patient, both proce­
dures have shown both success and disappointment, and
future study will clarify the indications. Lymph node trans­
fer is conceptually appealing as it replaces the lymph nodes
that were removed during surgery, providing not only an
exit for lymph but also restoring a major immunologic
organ. VLNT does not require specialized instrumentation
and applies techniques familiar to all microsurgeons. Most
reports demonstrate increased benefit over time, presum­
ably as lymphangiogenesis progresses. However, the poten­
tial risk of donor site lymphedema has been the largest
barrier to its use.42–45 Reverse lymphatic mapping (RLM),
described later in this chapter, has addressed this issue in
reducing potential morbidity.19
On the other hand, one of the most compelling argu­
ments for LVA is that it is minimally invasive, is apparently
low-risk, and can be performed under local anesthesia.
Limitations of LVA are that it depends on the status of the
lymphatic vessels of the patient, it requires specialized
instrumentation, and it is technically demanding. Questions
regarding the long-term patency and efficacy of the tiny
anastomoses have also come into question, although there
are long-term successes reported. While many surgeons in
the microsurgical community have adopted Koshima’s
supermicrosurgical technique of LVA, it is important to note
that the term “LVA” is often used interchangeably with
Campisi’s technique. Campisi’s vast experience with anasto­
mosis of larger deep lymphatic vessels to larger proximal
veins has also shown good results, and is a very different
procedure from Koshima’s, which is the subject of the fol­
lowing section.15,52–54
LYMPHATICOVENULAR ANASTOMOSIS
OPERATIVE TECHNIQUE
Lymphaticovenular anastomosis was first described by
O’Brien and has since been through periods of enthusiasm,
skepticism, and now resurgence.14,50,55–57 Two significant
reasons for the renewed popularity is the development of

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
49
anastomoses in the hopes of preserving their patency,
including gentle massage of the fingertips if the LVA was
performed in the hand or wrist. The effects can be appreci­
ated intraoperatively and are continued in the perioperative
period. Any significant compression is generally avoided in
the first 2 weeks following surgery. There is currently no
consensus on a postoperative compression regimen, but all
patients are generally back in the care of their lymphedema
therapist in the postoperative period.
TREATMENT OF UPPER EXTREMITY
LYMPHEDEMA WITH LYMPH
NODE TRANSFER
FLAP OPTIONS
We have yet to find one ideal donor site for VLNT, but it is
important to be familiar with several options because some
of these donor sites may not be available.4,17,19,64–71 The most
commonly used flaps include the groin, axilla, supraclavicu­
lar, and submental/submandibular flaps. A midcervical
flap based on superior thyroid vessels has been recently
used, which does not risk donor site lymphedema (Babak
Mehrara, pers. comm., October 2014). The omentum has
anastomosed to the end of a proximal vein. This allows for
bidirectional drainage into the proximal vein. While con­
ceptually appealing, this is also technically challenging.
Placing a temporary microvascular clamp proximally on the
lymphatic vessel will allow it to dilate to a point where creat­
ing the window and performing the anastomosis is more
feasible. Using the parachute technique and/or intravascu­
lar stenting methods can minimize back-walling these tiny
anastomoses. A nylon suture 2/5 the width of the lymphatic
vessel, is sharply cut with a blade (and not a scissors, to avoid
creating a barb) and is introduced intraluminally into the
lymphatic vessel and vein across the planned anastomotic
site. This allows for enough room to pass a needle while
blocking it from back-walling the vessel. The stent is removed
prior to tying the last knot. When the lymphatic vessel is
much smaller than the neighboring vein, a variety of alter­
native arrangements have been used such as a side-to-side
anastomosis or the “Pi” arrangement, where the lymphatic
is divided and both proximal and distal ends are attached
end-to-side to a single larger vein (Fig. 8.7).
POSTOPERATIVE MANAGEMENT
Many surgeons advocate some form of massage distal to the
most distal LVA in order to propel lymph across the
Figure 8.7  (A) Diagram of completed flow-through lymphaticovenous anastomosis, in which a Y-shaped vein (V) and lymphatic channel (L)
are anastomosed. (B) End-to-side lymphaticovenous anastomosis is performed when a similar size vein (V) and lymphatic channel (L) are
present, as shown in this diagram of completed anastomosis. (C) Intraoperative photograph of completed flow-through anastomosis. (D) Intra­
operative photograph of completed end-to-side anastomosis. A bent stent aids in performing the anastomosis. (Redrawn from Narushima, et al.
The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomosis. Plast Reconstr
Surg 2010;125[3]:935–43.)
Lymph
Lymph
Vein
Vein
B
A
C
D

50
PART 1 — PRINCIPLES
the wrist provided the greatest limb reduction in Chen’s
reported experience.72
We have used all three recipient sites with varying degrees
of success, but there are no data at this point comparing the
axillary donor site to more distal donor sites. In general, our
first choice is burying the flap in the axilla as we can remove
a scar, and address axillary vein stenosis if present, as well
as avoid a noticeable wrist flap, which our patient popula­
tion is sometimes averse to.
PREPARATION OF THE AXILLARY RECIPIENT SITE
If a prior axillary scar is present, this is typically used for the
approach. Subcutaneous flaps are elevated to expose the
axillary scar, the anterior border of the latissimus muscle,
the pectoralis major muscle, and the axillary vein. This dis­
section can be treacherous in patients with severe radiation
change, causing distortion of the brachial plexus, axillary
vein, and recipient thoracodorsal vessels. Once the thora­
codorsal vessels are identified, the axillary scar is completely
removed from the axillary vein and lateral chest wall to the
proximal upper limb until normal fat is exposed (Fig. 8.8).
The inflow of the thoracodorsal vessels is carefully con­
firmed and often requires more proximal division. If the
thoracodorsal vessels are unavailable, then the circumflex
scapular vessels or posterior humeral circumflex vessels can
be used. If the lymph node transfer to the axilla is ultimately
unsuccessful or the axilla is too hostile a recipient site, we
have also performed lymph node transfer to the forearm
using the recurrent radial vessels as recipients. This typically
requires a small skin paddle, but can be buried in some
cases.
VASCULARIZED GROIN LYMPH
NODE TRANSFER WITH REVERSE
LYMPHATIC MAPPING
ANATOMY AND FLAP DESIGN
The target lymph nodes for vascularized groin lymph node
transfer are the superficial inguinal nodes most commonly
also been revisited because there is no risk of extremity
lymphedema.
The groin is one of the most commonly used donor sites
because of familiar anatomy, abundant tissue, and a discrete
scar. However, it has a short pedicle (typically 1–2 cm)
and a vessel caliber usually between 1–1.5 mm with a risk of
lower extremity lymphedema.
The axillary flap based on the thoracodorsal or lateral
thoracic vessels has a larger and longer pedicle with the
option for including a large skin paddle and muscle if
needed. We commonly use this as a buried flap in the
calf for lower extremity lymphedema or as a composite
lymph node – TDAP flap if skin is required to resurface a
severely radiated and contracted axilla for upper limb
lymphedema.
The supraclavicular flap provides a relatively small amount
of soft tissue and small skin paddle, but a longer pedicle
than the groin. However, it is technically more challenging
as the phrenic nerve, spinal accessory nerve, lung, right
lymphatic duct or thoracic duct, and a variable pedicle must
be negotiated.64 There is also a risk of upper extremity
lymphedema. If it is used to treat upper limb lymphedema,
it should be harvested from the contralateral side as the
major lymphatic collectors from the upper limb may pass
near or through these lymph nodes.
The submandibular or submental flap described by Ming-
Huei Cheng has a major advantage of avoiding any risk of
limb lymphedema.67 However, there is a possibility of injur­
ing the marginal mandibular nerve with subsequent lower
lip weakness and a scar beneath the mandibular border.
RECIPIENT SITE
There has yet to be conclusive data regarding the ideal
recipient site for a lymph node transfer. Two competing
theories regarding mechanism and, consequently, ratio­
nale for recipient site selection are the lymphovenous
shunting hypothesis proposed by Chen, and the lymphatic
bridge proposed by Becker. Becker advocates for burying
lymph nodes in the axilla following complete removal of
any existing scar, aiming to restore lymphatic continuity
across the lymphadenectomy site.65,66 Indeed, lymphoscin­
tigraphy studies and MRL studies have confirmed reconsti­
tution of afferent and efferent lymphatics into the VLNT in
some, but not all patients. In our own series, while at least
two-thirds of patients experienced improvement, only one-
third demonstrated uptake of the proximal lymph node
transfer on lymphoscintigraphy. The axillary recipient site
is also cosmetically desirable and allows the surgeon to
address other issues such as scar contracture, axillary vein
stenosis, or pain syndromes from neuroma or entrapped
nerves.
Cheng makes a compelling case for placing the lymph
nodes in the most dependent area at the wrist with a skin
paddle which has yielded the best results in his series.72–77
Cheng has confirmed shunting of lymph from the lymph
node flap into the vein that drains the flap both in animal
and human studies. This is possible through interconnec­
tions between the lymphatic sinuses and venules within the
lymph node itself where the circulation interacts with the
lymphatic system. If the patient does not want a visible flap
on the wrist, the forearm is used as a recipient site, although
Figure 8.8  Axillary recipient site following complete scar excision
down to the axillary vein with exposed of the thoracodorsal vessels
shown over the blue background.

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
51
draining the abdomen into the SCIA-based lymph nodes
targeted for harvest. A gamma probe is then used to locate
the lymph nodes draining the lower extremity, which are
avoided. Note that the gamma probe will also detect a
high signal strength over the area of the proposed flap
because it is picking up technetium from iliac nodes deep
to the flap.
The groin crease is first marked, as dissection should
never cross this inferior border of the flap. A line is then
drawn from the pubic tubercle and anterior superior iliac
spine (ASIS) corresponding to the inguinal ligament. The
target lymph nodes are located between these two lines (Fig.
8.11). If a skin paddle is required, a common dimension is
5 × 10 cm, although we generally avoid a skin paddle unless
skin replacement or maximum flap bulk is required. More
commonly, the incision is oriented obliquely, directly over
the path of the SCIA. The medial extent does not cross
much farther than the SIEA, as lymphatics from the lower
extremity often pass medial and deep to this vessel.
Figure 8.9  Illustration of the anatomic basis of a groin lymph node flap. Target nodes are clustered between the superficial inferior epigastric
vein and superficial circumflex iliac artery/vein. PT, pubic tubercle; ASIS, anterior superior iliac spine. (Redrawn from Dayan J, et al. The use of
magnetic resonance angiography in vascularized groin lymph node transfer: an anatomic study. J Reconstr Microsurg 2014;30[01]:41–16.)
Sartorius
Femoral artery
Femoral vein
Lymph nodes for transfer
Anterior superior
iliac spine (ASIS)
Pubic tubercle (PT)
Inguinal ligament
Superficial inferior
epigastric vein
Great saphenous vein
Superficial circumflex iliac
artery and vein
1/3 distance from
PT to ASIS
3cm
based on the superficial circumflex iliac artery (SCIA).
Based on prior anatomic study, these lymph nodes are
located above the groin crease and slightly below the ingui­
nal ligament. They tend to cluster at the junction of the
SCIA and SIEA, approximately one-third the distance from
the pubic tubercle and 3 cm perpendicularly below this line
(Fig. 8.9).17 When starting out, a handheld Doppler can
localize the SIEA and SCIA. When reviewing the MRA, the
side with the largest number and caliber of lymph nodes
with a healthy distance from the lower extremity sentinel
nodes is selected.
The morning of surgery, the patient is injected in the
first and second web space of the foot on the side of the
inguinal donor site then brought directly to the operating
room. Four 0.1 mL intradermal injections of indocyanine
green dye are administered across the lower abdomen on
the donor side, halfway between the umbilicus and the
inguinal ligament (Fig. 8.10). Once prepped and draped,
either the SPY or PDE is used to visualize the lymphatics

52
PART 1 — PRINCIPLES
recipient site defect, particularly if a large amount of axillary
scar is removed.
At this point, the SPY or PDE is used to confirm the pres­
ence of lymph nodes in the flap. Dissection is then carried
down to the abdominal wall and sartorius muscle fascia
superiorly and laterally, where the distal end of the superfi­
cial circumflex iliac artery/vein (SCIA/V) is divided. Flap
elevation proceeds lateral to medial, superficial to the sar­
torius fascia (Fig. 8.2, and Figs 13.1 and 13.2). There is a
branch from the SCIA that dives deep to the sartorius fascia,
but care must be taken to ensure that the main SCIA pedicle
is not inadvertently divided as it can emerge at medial
border of the sartorius muscle as you approach the femoral
triangle. Once medial to the sartorius muscle, the gamma
probe is then carefully aimed upward from the undersur­
face of the lymph node flap to interrogate it for the pres­
ence of technetium. If there is an intense signal present
(>30% of the lower limb sentinel node), the site is aban­
doned and an alternative site (often the supraclavicular
donor site) is used. For this reason, informed consent is
always obtained for the possibility of a donor site change if
the lymphatic drainage patterns are abnormal. In the past
5 years, we have had two patients with significant uptake of
technetium in SCIA-based lymph nodes, which prompted a
site change, underscoring the fact that solely using anatomic
landmarks without a physiologic method such as reverse
lymphatic mapping may lead to the inadvertent harvest of
lymph nodes contributing to lower extremity drainage.
If the gamma probe does not detect significant uptake of
technetium in the target nodes illuminated by the SPY/
PDE, the SCIA pedicle is completely dissected in retrograde
fashion as the flap is incrementally divided along its inferior
and superior borders. Superficial veins of any significant
caliber (Fig. 13.19) on the inferior border of the flap are
dissected proximally and divided in case the vena comm­
itante of the SCIA is tiny. The investing fascia over the
femoral artery is incised superiorly as the SCIA and vena
commitante turn upward. Dissection is carried down to the
take-off of the femoral artery. While the vena commitante is
often adequate in caliber, there are some cases where it is
tiny and the proximal superficial inferior epigastric vein
(SIEV) or unnamed superficial vein must be used.
The next decision is how medial to extend the flap dis­
section. Once you enter the territory medial to the SIEV,
lymphatics draining the lower limb can be disrupted, and
for this reason, the gamma probe is used to determine
which lymph nodes are “hot.” No chances are taken in this
regard, and if there is any question about the role of a lymph
node in limb drainage, it is preserved. In general, the SIEV
(Fig. 11.7) is sometimes included in this flap but if it is
included, dissection is limited just medial to the SIEV. As
lymphatic drainage patterns vary, there are some situations
where the gamma probe demonstrates high signal intensity
along the region of the SIEV and it is excluded from the
flap. These decisions are completely guided by the RLM
technique and vary from patient to patient. Once the medial
border is determined, the flap is isolated on its pedicle and
harvested (Fig. 8.12). For documentation purposes, a
10-second count is taken of the flap as well as the sentinel
lymph node draining the limb. The signal intensity of the
flap should be no more than 10% of the sentinel lymph
node, and ideally, as low as possible. Finally, it is not enough
Dissection is carried down to just above the Scarpa’s fascia,
as the lymph nodes reside deep to this fascia. Subcutaneous
flaps are elevated superficial to Scarpa’s fascia, but no lower
than the groin crease. The superior border of the flap can
be extended to include more soft tissue bulk to fill the
Figure 8.10  Schematic of reverse lymphatic mapping. (Redrawn
from Dayan J. et al. Reverse lymphatic mapping: a new technique for
maximizing safety in vascularized lymph node transfer. Plast Reconstr
Surg 2015;135[1]:277–85.)
Groin crease
Indocyanine green
Target nodes
Nodes to avoid
Technetium
Figure 8.11  Markings for vascularized groin lymph node transfer.

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
53
are performed distally, and with good success. These are
commonly performed to either the posterior tibial or dor­
salis pedis vessels at the ankle, which requires a skin flap.
The bulk is unfortunately unsightly and may also interfere
with footwear.
To address the shortcomings of the ankle recipient site,
we now routinely use the medial sural vessels in the calf as
a recipient site, obviating the need for a skin paddle. The
axillary lymph node transfer to the medial sural vessels is
often our first choice for treatment of gynecologic tumor-
related lower extremity lymphedema with the supraclavicu­
lar flap as a back-up, if the axillary nodes are too close in
proximity to the lymph nodes draining the upper limb. The
axillary flap scar is well-concealed and there is minimal pain
in our experience compared with the supraclavicular flap.
For melanoma or sarcoma-related lower extremity lymph­
edema where the lymphatic defect is on the limb itself,
consideration is given to placing the lymph nodes at the site
of the defect, particularly if there is an acquired severe vein
stenosis due to surgery and/or radiotherapy that warrants
treatment.
VASCULARIZED AXILLARY LYMPH
NODE TRANSFER WITH REVERSE
LYMPHATIC MAPPING
DONOR SITE
Patients with an MRA demonstrating plentiful lymph nodes
inferiorly situated well below the level of the axillary vein
(presumably far away from lymph nodes draining the upper
limb) are the best candidates for vascularized axillary lymph
node transfer. There is considerable variability seen on
MRA, and it is common for one side to be preferable in
terms of lymph node caliber, number, and position. Lymph
nodes on the anterolateral chest wall are often supplied by
the lateral thoracic vessels while lymph nodes along the
undersurface of the latissimus and posterolateral chest wall
are typically supplied by the thoracodorsal artery. Ultimately,
a decision to use one or both of these pedicles must be made
during the course of the procedure. Of paramount impor­
tance is to avoid lymph nodes close to the axillary vein,
which should never be skeletonized or visualized during
dissection. The patient should be aware that there is a risk
of losing sensation under the arm if the intercostobrachial
cutaneous nerve is divided, although dissection typically
remains just below this nerve. If the thoracodorsal vessels
are used, there is a possibility that the thoracodorsal nerve
is intertwined between the pedicle and lymph nodes and
must be divided and reapproximated following flap harvest.
The technique of reverse lymphatic mapping is critical
in this procedure because axillary nodes are in a highly
mobile mass of adipose tissue where they can easily change
position. The morning of surgery the patient has 0.2 mL of
filtered technetium injected into the first and second web
spaces of the hand. For those embarking on this procedure
for the first time, a longitudinal incision along the lateral
chest wall is most straightforward, although this often results
in a widened scar. We typically mark a transverse axillary
incision at least 4–5 cm below the axillary crease for better
cosmesis (Fig. 8.14). Four 0.1 mL intradermal injections of
to preserve the critical lymph nodes draining the lower
limb, their vascularity must be maintained as well. Small
feeding branches to “hot” nodes must be carefully preserved
and flap division should not occur in tight quarters to these
nodes, but with a healthy distance allowing for preservation
of not only the lymph node but its perinodal fat. Anastomo­
sis is then performed to the thoracodorsal vessels and the
flap is carefully inset directly onto the axillary vein with
closure over a closed-suction drain (Fig. 8.13).
TREATMENT OF LOWER EXTREMITY
LYMPHEDEMA WITH VASCULARIZED
LYMPH NODE TRANSFER
The proximal versus distal recipient site dilemma exists in
lower extremity lymphedema as well. However, many forms
of lower extremity lymphedema are a result of hysterectomy
and radiotherapy for gynecologic tumors. Venturing deep
within the pelvis to restore lymphatic continuity is often
impractical, and consequently, most lymph node transfers
Figure 8.12  Groin lymph node flap isolated on the superficial cir­
cumflex iliac artery and vena commitante with the inguinal ligament
retracted superiorly with a double hook.
Figure 8.13  Groin flap inset directly on top of the axillary vein fol­
lowing anastomosis to thoracodorsal vessels. Flap spans the defect
created by scar removal from lateral chest wall to normal upper limb
subcutaneous fat.

54
PART 1 — PRINCIPLES
thoracic vessels. The proximal lateral thoracic vessels are
explored to determine if an artery is present or not. If there
are plentiful lymph nodes supplied by the lateral thoracic
vessels and an adequate artery and vein are present, the
decision to harvest this flap alone may be made. If there is
not a lateral thoracic artery present or if more lymph nodes
are desired, dissection proceeds posteriorly to include the
thoracodorsal vessels as well. Conversely, if the MRA dem­
onstrated plentiful thoracodorsal-based lymph nodes, the
flap could solely be based on the thoracodorsal pedicle.
However, we have observed a trend toward improved effi­
cacy with a greater number of lymph nodes and will often
harvest both pedicles provided that there is no technetium
signal present (Fig. 8.16). Distal pedicles of the lateral tho­
racic and thoracodorsal vessels are divided and care is taken
to avoid the long thoracic nerve. The gamma probe is used
throughout this process to ensure that the superior extent
of the lymph node flap does not encroach upon any hot
lymph nodes draining the upper limb. One final key in this
process is not to skeletonize the proximal pedicles more
proximally in the territory of the nodes draining the upper
limb. Even if these nodes are preserved, proximal skeletoniza­
tion of the pedicles may devascularize the lymph nodes draining the
upper extremity and should be avoided. If a small branch is
feeding a hot node from the pedicle of your flap, the pedicle
should be harvested distal to this branch to preserve circula­
tion to the sentinel node.
RECIPIENT SITE PREPARATION
MEDIAL SURAL VESSELS
The medial sural artery and vein can be rapidly prepared
for lymph node transfer to the calf. The medial gastrocne­
mius muscle is palpated and a 10 cm longitudinal incision
is marked from the popliteal crease inferiorly over the
center mass of this muscle belly. The location of the greater
saphenous vein is marked anteriorly and the sural nerve is
marked in the median raphé to designate the outer limits
indocyanine green is injected approximately 10 cm below
the planned incision across the back an lateral chest wall.
The gamma probe is used to identify the location of the
sentinel nodes draining the upper limb, which are marked
and carefully avoided. These lymph nodes are on the under­
surface of the superolateral border of the pectoralis major
muscle (Fig. 8.3). Subcutaneous flaps are then elevated to
expose the flap (Fig. 8.15). The SPY/PDE is used to identify
the presence of nodes and make an assessment of where the
greatest number of nodes is located. The gamma probe is
used again to determine the superior extent of the flap
where no technetium signal is present. This level is marked
with a marking pen and is continuously examined with the
gamma probe throughout the dissection. There should be
almost no signal present in the flap. The trick here is to
ensure the presence of nodes in the flap, while keeping a
safe distance from any lymph nodes draining the upper
limb. At this point, dissection is carried directly to the
anterolateral chest wall just posterior to the pectoralis major
muscle. A subfascial plane is used to capture the lateral
Figure 8.14  Axillary flap markings.
Figure 8.15  Axillary flap exposed. Depending on the patient’s
anatomy, flap is based on either or both the lateral thoracic and
thoracodorsal vessels.
Figure 8.16  Axillary flap harvested. The superior pedicle is the
lateral thoracic vein. In this case, the lateral thoracic artery was
absent so the thoracodorsal vessels and corresponding lymph
nodes were included as well. One artery and both veins were
anastomosed.

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
55
VASCULARIZED SUPRACLAVICULAR
LYMPH NODE TRANSFER WITH
REVERSE LYMPHATIC MAPPING
The supraclavicular flap is another common option for
lymph node transfer. It was initially favored because of the
misperception that there is no risk of upper extremity
lymphedema, but this has since been shown to be false. This
has prompted us to use a modified technique of reverse
lymphatic mapping that identifies not only potentially criti­
cal lymph nodes to upper limb drainage but also the right
lymphatic duct and thoracic duct, which can be injured
during dissection. A dose of 0.2 mL of filtered technetium
is injected into the first and second web spaces of the hand
prior to surgery, and 0.5 mL of indocyanine green is injected
into the medial upper arm, which is massaged proximally.
The gamma probe is used to sweep for any hot nodes in the
supraclavicular region. If they are present, the site is aban­
doned. The indocyanine green dye will highlight major
lymphatic ducts using near infrared imaging, which are criti­
cal to upper limb drainage.
Thorough knowledge of anatomy of the supraclavicular
region is critical to safely elevating this flap, which is based
on the transverse cervical artery (see Ch. 33; Fig. 11.1 and
Fig. 8.1). This artery commonly originates from the thyro­
cervical trunk, situated on the subclavian artery. However,
there can be significant variability and it may originate from
the suprascapular artery or directly from the subclavian
artery as well. Venous drainage of the flap can be based on
the transverse cervical vein, which is also variable or from
the external jugular vein. Major lymphatic ducts can be
encountered during dissection and have variable entry
points into the internal jugular vein and subclavian vein.
The phrenic nerve, spinal accessory nerve, and brachial
plexus are all in the field of dissection. Patients should be
aware they will have loss of sensation in the supraclavicular/
upper chest region because of division of supraclavicular
nerves that pass through this flap. Some patients may
also experience temporary but profound neuropathic pain
as well.
Figure 8.18  Exposure of medial sural vessels.
Figure 8.19  Flap inset with thoracodorsal artery, vein, and lateral
thoracic vein anastomosed to medial sural vessels.
Figure 8.17  Marking for the medial sural recipient vessels.
of dissection, as these structures should be avoided (Fig.
8.17). An incision is carried directly down through the deep
muscle fascia, and then subfascial flaps are elevated to
expose the medial sural artery perforators. The largest per­
forator is selected and a retrograde intramuscular dissection
is performed, which will lead to the medial sural vessels,
which are mobilized proximally as required for anastomosis.
The veins are typically large (2–3 mm) but the artery is
consistently in the neighborhood of 1.5 mm. Preoperative
MRA can be helpful in assessing the branching patterns. If
both the lateral thoracic and thoracodorsal artery and veins
are to be anastomosed, there is often a large bifurcation of
the medial sural vessels making four anastomoses quite
straightforward (Fig. 8.18). The final step is to excise a
window of the deep investing muscle fascia and a portion
of the subcutaneous fat to allow room for the lymph node
flap and ingrowth of new lymphatics. Care must be taken to
limit the width of dissection in order to avoid the greater
saphenous vein and sural nerve. Anastomosis is performed
to all proximal vessels that are present, which is dependent
on the anatomic variability of the patient (Fig. 8.19).

56
PART 1 — PRINCIPLES
flap and are divided, they can be anastomosed to large
neighboring veins to restore their physiologic function and
avoid the risk of lymphedema. We have encountered a situ­
ation where these ducts required lymphovenous anastomo­
sis as they passed through the lymph node flap. We have
also encountered a scenario where the medial-most supra­
clavicular nodes were hot when inspected with the gamma
probe and the flap was modified to preserve these lymph
nodes.
POSTOPERATIVE MANAGEMENT
All lower extremity lymph node transfers are kept non-
weightbearing for 2 weeks with a walker and daily prophy­
lactic enoxaparin. Compression is completely avoided
except for over the foot during this period. After 2 weeks,
the patient is seen by a lymphedema therapist and can start
compression wrapping over the entire limb, including the
area of the lymph node flap. Regarding ambulation, the
patient is instructed to place 25% weightbearing on the limb
for 2 days after the 2-week period, followed by 2 days at 50%,
2 days at 75%, then full weightbearing. The purpose of this
gradual increase is to avoid inflammation, which could pre­
cipitate swelling. At 6 weeks the patient returns to full
normal activity. Between 6 and 8 weeks, the patient is often
fitted for a custom compression garment, although this can
vary depending on the patient’s response to surgery and
therapy. In general, the patient is under close care of a certi­
fied lymphedema therapist for 6 months. There is often the
question of a standardized postoperative therapy protocol,
which has yet to be developed. However, patients have dif­
ferent stages of lymphedema that respond differently, and
so the therapy is often guided by the individual patient and
therapist with the main clinical end-point being the most
effective volume reduction in the limb.
OUTCOMES
While there have been several reports on outcomes follow­
ing lymphatic surgery, most of these have focused on limb
volume, which can easily be manipulated by postoperative
compression. Even if this is controlled for, many other
FLAP MARKINGS AND ELEVATION
Most commonly we will not include a skin paddle and will
orient the incision parallel to Langer’s lines midway between
the clavicle and the base of the neck to minimize the
scar. The sternal notch, sternocleidomastoid, and external
jugular vein are all marked for orientation (Fig. 8.20). A
skin paddle can be included if desired with the perforator
located at the midclavicular line.
The incision is carried down through the platysma and
flaps are elevated to expose the supraclavicular fat pad in a
subplatysmal plane. The external jugular vein will traverse
the superficial surface of this flap and is divided at the supe­
rior border. The external jugular vein is dissected proxi­
mally at the inferior border and divided with a microvascular
clamp placed on the flap side as it may be required for
venous outflow. The sternocleidomastoid is exposed and
retracted medially. Dissection is carried deep along the
border of the sternocleidomastoid where the omohyoid
muscle is divided, which will bring the internal jugular vein
into view. Dissection can then proceed from a lateral and
superior approach where the inferior belly of the omohyoid
is divided. Relatively large branches of the supraclavicular
nerve pass through the flap at the superior margin and must
be divided. The flap is elevated from the trapezius muscle
where the spinal accessory nerve is carefully avoided. As
dissection continues medially over the anterior scalene
muscle, the phrenic nerve is preserved where it lies on the
superficial surface and the brachial plexus is avoided deep
to this muscle. At this point, the transverse cervical artery
and vein are explored, which arise deep and inferiorly near
the base of the anterior scalene muscle. On occasion, the
transverse cervical vein is not draining the flap and the
external jugular vein is used instead (Fig. 8.21).
During the course of this dissection, near infrared imaging
is used to confirm the location of major lymphatic ducts,
which are avoided, or if they pass through the lymph node
Figure 8.20  Supraclavicular flap markings.
Figure 8.21  Supraclavicular flap elevated.

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
57
CONCLUSION
There is a broad array of techniques available to treat
lymphedema, and the indications for these procedures are
steadily coming to light. Lymphaticovenular anastomosis
and vascularized lymph node transfer are among a variety
of procedures that offer promise for many patients who
suffer greatly from a disease frequently orphaned by the
medical community. Undoubtedly, the practice of lymphatic
surgery will look significantly different 5–10 years from now.
These incremental insights are small steps in the right direc­
tion, where future multidisciplinary collaboration will move
this field forward.
variables come into play such as the season (warm or cool),
salt intake, weight loss or gain, or level of exertion the day
the measurements were taken. While limb volume is impor­
tant to document, the patient’s preoperative and postopera­
tive compression regimen should be recorded, as well as
their weight. Because limb volume is a moving target, if a
patient has a physiologic procedure, additional outcome
measurements are required for credibility. Patient-reported
outcomes using a questionnaire such as the ULL-27 become
useful when objective outcomes are limited in nature.78,79
Postoperative lymphoscintigraphy, IGL, and MRL are all
complementary assessments, and more recently histologic
study allowed us to gain insights into outcomes on a cellular
level.51
Expert Commentaries 
David W. Chang, MD, FACS
I would like to congratulate the authors on this very well-written
chapter on surgical treatment of lymphedema. Lymphedema is
a chronic, debilitating condition that causes physical and psy-
chological morbidity. Unfortunately, no definitive treatment
for lymphedema currently exists. Physiologic methods, such as
vascularized lymph node transfer or lymphovenous bypass,
attempt to restore functional lymphatic drainage.
The advances in microsurgery, and more recently supermi-
crosurgery, have had a major effect on the evolution of these
physiologic procedures, which have gained popularity to help
reduce the severity of lymphedema. One recent technologic
advance is the use of indocyanine green fluorescence lymphan-
giography to map lymphatic vessels. Indocyanine green fluo-
rescence lymphangiography enables surgeons to locate and
make incisions precisely over functional lymphatic vessels for
the lymphovenous bypass, significantly improving the out-
comes of lymphovenous bypass surgeries.
Autologous, or vascularized lymph node transfer aims to
bring vascularized tissue and healthy lymph nodes into sites
affected by lymphedema. One theory is that lymphangiogenesis
occurs via growth factors produced by the transplanted lymph
nodes and thereby bridge lymphatic pathways. Another theory
proposed is that vascularized lymph node transfer acts as a
lymphatic pump. However, one main concern with harvesting
lymph nodes is a possibility of causing donor site lymphedema.
The use of preoperative lymphoscintigraphy combined with the
use of intraoperative gamma probe to detect and preserve
“sentinel” lymph nodes can help minimize secondary lymph-
edema from harvesting of lymph nodes.
Currently, there is no cure for lymphedema. Worldwide inter-
est in using microsurgical procedures to treat lymphedema is
gaining momentum. However, there is no consensus on the
indications for which procedure to perform, when to intervene,
or how to comparatively grade outcomes. We need further
research and better understanding of lymphatic anatomy and
lymphedema pathophysiology. In addition, more prospective
and controlled studies are needed to objectively evaluate the
outcomes of various treatment methods.
Ming-Huei Cheng, MD, MBA, FACS
This chapter by Joseph Dayan, Jaume Masia, and Isao Koshima
provides a thoughtful and extensive overview of anatomy
and physiology, diagnostic tools, surgical indications and tech-
niques relevant to lymphedema. The authors detail reverse
lymphatic mapping for lymph node flap harvest, lymphovenous
anastomosis (LVA), and vascularized lymph node (VLN) flap
transfer using three donor site options.
The LVA was introduced by Yamada in 1969 before being
modified and popularized by Koshima, more recently. Many
surgeons would agree that it is most effective for early treat-
ment of breast cancer–related upper limb lymphedema. LVA is
performed by anastomosing residual functional lymphatic
collecting ducts to subdermal veins with the assistance of
indocyanine green fluorescence lymphography, specialized
microscopes capable of ×40 magnification, and supermicrosur-
gical methods. The surgical technique of LVA requires practice
with a slow learning curve. Improvements in postoperative
monitoring and long-term follow-up after LVA warrant further
investigation.
In addition to superficial groin lymph node basins, submental,
supraclavicular, thoracic (axillary), and intra-abdominal (omental)
lymph nodes have been described in microvascular transfer.
Because outcomes measures are not standardized, large mul-
ticenter series do not exist. Establishment of a gold standard
outcomes measure that allows comparisons between different
methods is a major aim of lymphedema research. The concept
of reverse lymphatic mapping for decreasing the donor site
morbidity is an important contribution in VLN flap transfer.
Improvements at donor and recipient sites alike will promote
acceptance of VLN flap transfer among surgeons and patients.
At the time of writing, the role of reverse lymphatic mapping
lacks adequate data to support its favorable influence on the
risk:benefit balance for VLN flap transfer.
The location of optimal VLN flap recipient sites remains con-
troversial. Recent data are in support of distal recipient sites,
such as the wrist, versus proximal sites such as the elbow. For
example, patients who have undergone VLN flap transfer to
distal recipient sites do not require compression garments
postoperatively. One disadvantage of the distal recipient site is
the bulky and often unsightly flap, though this can be revised
postoperatively.
Goals of treatment of lymphedema include (1) decreased
limb firmness, swelling, and volume; (2) decreased cellulitis and
infection rates; (3) increased quality of life, eliminating the need
for compression garments; (4) minimal donor site morbidity;
and (5) improved appearance of the recipient site. Prioritization
of these goals, selection of available surgical options, and
donor and recipient site choice are surgeon-dependent and
should be evaluated on a case-by-case basis.

58
PART 1 — PRINCIPLES
Figure 8.22  Lower extremity lymphedema treated with lymph node transfer. (A) Thoracodorsal artery-based lymph node flap to the
medial sural vessels. (B) Preoperative photograph of the right lower extremity lymphedema. (C) A 1-year postoperatively following lymph
node transfer to the calf. (D) Postoperative lymphoscintigraphy at 1 year, demonstrating uptake of technetium into transferred lymph nodes
in the calf. (E) Preoperative MRA demonstrating approximately 50/50 contribution of fluid and fat hypertrophy to limb volume. (F) Postop­
erative MRA at 1 year, demonstrating reduction in fluid component but persistence of fat hypertrophy. (G) Postoperative MRA demonstrat­
ing seven viable lymph nodes at the calf recipient site.
A
B
C
D
E
F
G
A young woman presented with secondary lower extremity
lymphedema of the right leg following trauma. She had a history
of cellulitis, despite compliance with compression garments.
Work-up involved lymphoscintigraphy, which demonstrated
diffuse dermal backflow in the calf with some groin lymph node
drainage. MRA demonstrated a fluid component of approxi-
mately 50% contribution to the limb volume with fat hypertro-
phy. The patient underwent a thoracodorsal artery-based lymph
node transfer to the right calf (Fig. 8.22A). Postoperatively, she
had a reduced need for compression (grade 2 garment down
from a grade 4 garment), as well as a reduced limb volume (Fig.
8.22B,C). Postoperative lymphoscintigraphy at 1 year demon-
strated uptake of the transferred lymph nodes to the calf (Fig.
8.22D). Postoperative MRA demonstrated reduced fluid compo-
nent of her lymphedema, while the fat hypertrophy component
remained unchanged (Fig. 8.22E,F). MRA also demonstrated a
total of seven viable vascularized lymph nodes at the recipient
site (Fig. 8.22G).
CASE 8.1  Lower Extremity Lymphedema Treated with Lymph Node Transfer

CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
59
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CHAPTER 8 — Lymphedema: M
icrosurgical Reconstruction
59.e1
A 52-year-old woman with a grade II secondary lymphedema after
left breast cancer treatment (modified radical mastectomy +
radiotherapy) in 2003. The lymphedema started in January 2006
with proximal development. ICG and lymph-MRI assessments
showed that only lymphatic channels below the elbow were active.
We did three LVAs in February 2011 and 4 years later, she has a
significant and stable improvement without any compression
garment on the forearm lymphedema (2–3 cm less).
CASE 8.2  Upper Extremity Lymphedema Following Mastectomy Treated with
Lymphaticovenular Anastomoses
Figure 8.23  Upper extremity lymphedema following mastectomy treated with lymphaticovenular anastomoses. (A) Preoperative measure­
ments (after 12 weeks of decongestive lymphatic therapy). (B) Preoperative lymphatic mapping (red lines: lymph-MRI information; green
lines: ICG preoperative assessment). (C) Skin incision approach (1.5 cm) with a lymphatic channel and a subdermal venula dissected. (D)
Lymphatic channel (inferior) full with Blue Patent V dye and subdermal venula (superior). (E) Lymphovenous anastomosis with 11/0 suture.
(F) Lymphovenous anastomosis after 5’ of distal massage with lympha transfer to the venous system. (G) Immediate postoperative draw­
ings showing the type of LVAs. (H) At a 4-year follow-up, showing a significant stable reduction of the perimeter at the forearm level.
A
E
F
G
H
B
C
D
B

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e36
INTRODUCTION
In recent years, robotic surgery has grown to dominate mini­
mally invasive applications in the various surgical subspecial­
ties. The currently available robotic surgical platform (da
Vinci, Intuitive Surgical, Sunnyvale, CA) consists of two inte­
grated subsystems: a surgeon console and a patient side cart
(Fig. 9.1). While seated at the console, the surgeon controls
the instruments and endoscope using two small hand-
operated mechanisms residing within the console (Fig. 9.2).
The instruments themselves are capable of supination, pro­
nation, flexion and extension, and grasping, much like the
human hand, making them considerably more agile than
standard endoscopic instrumentation (Fig. 9.3). The endo­
scope (Fig. 9.4) provides two independent images that are
fused to form a 3-dimensional (3-D) view at the console.
OPERATING INTERFACE
The basic surgical robotic interface is what is referred to in
engineering as a “master-slave” model. The surgeon sits at
a console and controls the movements of the arms and
instruments remotely, but in real-time. The movements per­
formed by the surgeon are mimicked precisely by the move­
ments of the robotic arms and wrists. The hand controls
are designed in such a way that gross movements of the
surgeon’s arms in space translate into movements of the
large robotic arms, and finer movements of the surgeon’s
wrist and fingertips are translated into fine motion at the
tips of the instruments, which are controlled by a pulley
system.
Instrument motion is very smooth and precise. Tremor is
eliminated completely and motion paths of the robotic
instruments are smaller and smoother than the surgeon’s
own motion. There is no haptic, or sensory, feedback deliv­
ered by the robotic interface, so there is no force feedback
to aid the surgeon in understanding tissue reaction. This is
cited as the principal disadvantage of the robotic surgical
interface. All data about tissue reaction must be extracted
Robotic Applications in
Plastic and Reconstructive
Surgery
Jesse Selber
9 
Figure 9.1  The da Vinci system is composed of integrated sub­
systems. A surgeon console where the surgeon sits, a patient side
cart, which interacts directly with the patient, and a vision tower,
which houses the central processing unit, camera, light source, and
monitor. (©2016 Intuitive Surgical, Inc. Used with permission.)
Figure 9.2  The surgeon controls the robotic arm (A) using two hand-
operated mechanisms that reside within the surgeon console (B).
(©2016 Intuitive Surgical, Inc. Used with permission.)
A
B
PART 1  —  PRINCIPLES

CHAPTER 9 — Robotic Applications in Plastic and Reconstructive Surgery
e37
for specific procedures and understanding how to trouble­
shoot a machine that is not performing optimally requires
much more experience. It is critical to work with a skilled
scrub assistant who is trained in instrument use and
exchange, calibration and cleaning of the endoscope and
camera, port management, and vision tower control, par­
ticularly in the beginning. In addition, working with another
physician who can remain at the bedside and manage con­
flicts among arms and provide other additional information
to the operating surgeon that may be outside her/his field
of view is extremely helpful, again particularly early on.
Having a good team in robotic surgery is analogous to a pit
crew in racing. If you have a good team, you can make
adjustments and transitions quickly and seamlessly. If your
team is unsure about the technology, its use will be a burden
in both time and effort. Ultimately, it is the surgeon’s
responsibility to understand the robot better than everyone
else in the room.
Although only recently introduced to plastic surgery, the
superb precision and high resolution, 3-D optics make the
surgical robot a valuable and versatile plastic surgical tool.1,2
In this chapter, three general applications of robotics in
plastic surgery are discussed:
1. Trans-oral robotic reconstructive surgery for head and neck
reconstruction, permitting complex oropharyngeal
reconstruction without dividing the lip or mandible
2. Robotic muscle harvest, permitting an “incisionless” harvest
of both the latissimus dorsi and rectus abdominis muscles
3. Robotic microvascular anastomoses, extending the capabili­
ties of the human hand in challenging microsurgical
scenarios.
TRANSORAL ROBOTIC SURGERY (TORS)
TORS was developed to resect tumors in the oropharynx,
avoiding the morbidity of mandibular swing procedures and
high-dose chemoradiation therapy.3–6 It has since been
adopted at multiple other centers, and was FDA approved
in 2009. Initially, the standard following TORS resections
was that oropharyngeal defects were left to heal by second­
ary intention.7,8 This approach is reliable for smaller tumors,
but is suboptimal when a significant anatomic defect is
created, vital structures are exposed, or a surgical fistula is
created. To mitigate reconstructive access to a severely con­
strained physical space, transoral inset of a free flap or local
flap using robotic assistance has been shown to be both
feasible and effective (Fig. 9.5).9,10 By taking this approach,
the plastic surgeon can provide the reconstructive support
for the head and neck surgeon to remove larger and more
complex tumors robotically that would be very difficult to
reconstruct through traditional methods.11,12
INDICATIONS
Any oropharyngeal resection in which reconstruction is nec­
essary and direct visualization through the mouth or phar­
yngotomy is inadequate for inset.
ROBOTIC MUSCLE HARVEST
Free and pedicled muscle flaps have been in use by plastic
surgeons for a variety of applications since the First World
from visual information which is interpreted by the surgeon
based on previous experience. Although a theoretical
concern, in the author’s training, this required only a brief
cognitive adjustment period to overcome.
ROBOTIC OPERATING TEAM
Because of the highly complex nature of the machine and
its underlying technology, a skilled team must be present to
operate it. Sitting down at the console and using the arms
is the easiest part of robotic surgery. Setting the machine up
Figure 9.3  The robotic instruments are capable of “wristed motion,”
which entails 7 degrees-of-freedom at the tips of the instruments,
including flexion, extension, pronation, supination, radial and ulnar
deviation, and grasping. This movement mimics those of the human
hand and wrist. (©2016 Intuitive Surgical, Inc. Used with permission.)
Figure 9.4  A 12 mm and 8.5 mm endoscope. The endoscope
contains two cameras and a light source. The separate cameras
convey an image to each eye, accounting for the 3-dimensional
image in the surgeon console. There are also 30° and 70° up and
down scopes to increase viewing versatility. (©2016 Intuitive Surgical,
Inc. Used with permission.)

e38
PART 1 — PRINCIPLES
War, and remain workhorses in scalp, extremity, head and
neck, and breast reconstruction. Harvest of these flaps
usually requires incisions that allow access to muscle origin,
insertion, and pedicle. Incisions can range from 20 cm to
40 cm in length and can result in significant donor site
morbidity.13,14 The robotic interface has supplied the neces­
sary exposure, picture clarity and precision to accomplish
both muscle and pedicle dissection, with minimal external
incisions and donor site morbidity.
Harvest of the latissimus dorsi muscle can be performed
with no new incisions beyond those needed for a mastec­
tomy. Dissection of the pedicle and anterior border of the
muscle can be performed through either the sentinel lymph
node biopsy incision or mastectomy incision alone, with two
additional ports that can be used for drain exit sites.15,16
When a free flap is needed, a short axillary incision will
suffice. Insufflation provides the optical window for dissec­
tion (Fig. 9.6, Video 9.1).
Harvest of the rectus abdominis muscle is done intraperi­
toneally, using three ports through the contralateral abdom­
inal wall, lateral to the linea semilunaris (Fig. 9.7).17 The
entire muscle and pedicle can be easily dissected for use in
the pelvis, or extracted using a laparoscopic retrieval bag for
a free flap. There is no violation of the anterior rectus
sheath (Video 9.2).18
INDICATIONS
1. Harvest of the latissimus dorsi when a skin island is not
necessary or desirable:
a. Free flap for scalp or extremity coverage
b. Pedicled flap for breast reconstruction in:
i. Delayed immediate breast reconstruction when
re-expansion is acceptable but long-term durability
of skin coverage is questionable19
Figure 9.5  The set-up for transoral robotic surgery. A mouth retractor is used to set the interdental opening. Teeth are protected with a
tooth guard and eyes with goggles or pads. The robotic patient side cart is placed next to the patient, typically at 30° to the foot of the surgical
bed. The three robotic arms are aligned around a point converging at the back of the oropharynx: two arms contain instruments and one
contains the endoscope.
Tooth guard
Robotic instruments
Mouth
retractor
Figure 9.6  The robot docking for the robotic latissimus dorsi
harvest. The patient is in the left lateral decubitus position. The
patient side cart is oriented to face the patient’s back, while the
robotic arms are delivered over the patient and nearly parallel with
the floor. Ports are placed anterior to the anterior border of the
muscle. The central arm is for the camera and should be flexed 90°
at the elbow. Arm 2 contains the Cadiere grasper and arm 1 contains
the monopolar scissors. There are no incisions that are not already
required for either the mastectomy, sentinel lymph node, or drains.
ii. Immediate implant-based breast reconstruction in
NAC sparing mastectomies as a superior alterna­
tive to lower pole coverage
iii. Oncoplastic reconstruction of the upper outer
quadrant in partial breast reconstruction