INTRODUCTION
The lymphedema is a pathological disabling
condition resulting from malfunction of the lymphatic
system and manifests as swelling, recurrent
infection and skin changes at the affected body
part [1]. Although many countries do not have
accurate statistical measures of such a condition,
an estimated five to ten million Americans suffer
from lymphedema nowadays [2]. The lymphedema
is a potential handicapping condition due to the
increase in weight and size of the affected limb as
well as decrease in its immunity [3]. Lymphedema
patients were offered compression, physical therapy
[4], de-bulking procedures [5] and other nonphysiological
procedures as the mainstay of treatment.
These traditional modalities could temporary
improve the size but not infection or disease
progress [4]. Since 1967, an experimental lymphovenous
bypass has been tried [6]. However, it did
not become a popular clinical practice until 1990th
when Koshima was able to produce an effective
functional bypass to drain the lymphatic fluid out
195
of the limb [7]. Since then, the reconstructive
lymphatic Microsurgery started to gain popularity
and many developments in that field rendered many
lifelong lymphedema conditions into a treatable
disease. The proved efficacy of reconstructive
lymphatic procedures nowadays changed the gold
standard treatment for lymphedema to be more
surgical and physiological [8]. Previously, it was
believed that the lymphatic vasculature played a
passive role by transporting antigen-presenting
cells and soluble antigens to regional lymph nodes.
However, the most recent studies show that lymphatic
endothelial cells regulate immune responses
more directly. They control the entry of immune
cells into lymphatic capillaries, present antigens
on major histocompatibility complex proteins, and
modulate antigen-presenting cells [2]. Thereafter,
a physiological lymphatic reconstruction shall
largely replace the previous practice.
Case Report
A 44 years old active gentleman was referred
to us from a vascular surgeon complaining of
recurrent attacks of cellulitis, trans-cutaneous
Lymphorrhea and intractable swelling despite the
maximum conservative measures for left lower leg
and foot lymphedema. Taking history and examining
the patient, we encountered a 23-year lasting
lymphedema (ISL stage: IIb-Campisi stage: III)
following multiple attacks of cellulitis at 19 years
of age. A hard slightly pitting edema with lymphorrrhea
sites from upper calf is seen no current
cellulitis Fig. (1). An ICG scan revealed a dermal
backflow pattern (star-sky appearance with diminished
lymphatic velocity). We decided, with the
patient's agreement, to operate of the patient's
lymphedema doing a free lymphatic tissue transfer.
We recommended preoperative maximum decongestive
therapy to facilitate the surgery and to give
us a clue about the expected decrease in the limb
size after fluid component removal but the patient
was incompliant. Another ICG scan was done for
the donor leg which confirmed that the lymphatic
tree is normal.
Pre-operatively, a superficial circumflex iliac
artery perforator flap (SCIP) flap was designed on
right groin (Fig. 2).
Intraoperatively, under (epi-dural) anesthesia,
a 15 X 6cm flap was raised containing lymphatic
channels only and no lymph nodes (the horizontal
group of superficial inguinal lymph nodes were
identified under magnification and preserved). In
order to include maximum lymphatic vessels, all
tissues above the deep fascia were harvested in
supero-lateral part of the flap and most of tissues
deep to Scarpa's fascia and lymph nodes were
preserved in the inferomedial part (Fig. 3). The
SIEA (superficial inferior epigastric artery) and
SCIV (superficial circumflex iliac vein) were anastomosed
to the posterior tibial artery (end to side)
and a superficial vein respectively. This was a
diviation from the original plan due to vascular
dominance by intraoperative selective clamping
test. A skin paddle was left for monitoring at the
time of insetting. Post-operative strict limb elevation,
a course of antibiotics and LMWH was administered,
dangling at 5 days, non-weight bearing
walk at one-week followed by partial then full
weight bearing at 21 days. Although the distal 3
cm of the flap required debridement and 2ry sutures
as a day surgery procedure after 4 weeks, no other
complications were noticed on donor or recipient
sites.
196 Vol. 44, No. 1 / The Isolated Effect of Vascularized Lymphatic Vessels Only Transfer
RESULTS
The patient lost 5cm of leg circumference at
10th post-operative day (Fig. 4). No single attack
of cellulitis or lymphorrhea happened postoperative
further improvement of skin quality and
stable leg circumference (of less than pre-operative)
without regular physiotherapy or effective compression
at 6 months post-operative (Fig. 5).
Fig. (1): Pre-operative measurements of left lower leg 10 and
15cm above medial malleolus.
Fig. (2): Left-pre-op. marking donor site (initially planned as
SCIP flap).
Fig. (3): Top: Intra-op. flap raised ( =Thin part of the flap,
=Thick flap part, =Deep surface of the upper
medial part of flap rolled) SIEA=Superficial Inferior
Epigastric, SCIA=Superficial Circumflex Iliac Artery.
Bottom: After flap inset with tube drain.
Egypt, J. Plast. Reconstr. Surg., January 2020 197
DISCUSSION
Due to recent advances in lymphedema surgery,
many procedures can be combined with the conservative
management to result in a better outcome
and the physiological and non-physiological procedures
would be combined as well [8,14]. In our
case, free lymphatic issue transfer was chosen
because of preexisting lymphatic destruction due
to previous attacks of cellulitis [15]. As active
collection and propulsion of lymphatic fluid is
done by lymphatic tubules [16], we hypothesized
that the lymph nodes have no superior role over
the lymphatic vessels in resolving the lymphedema
problem physiologically and mechanically, yet can
have a higher morbidity theoretically. Improvement
of lymphedema through providing healthy lymphatic
vessels with its collective and secretive
properties has been reported before [17]. Although
some might argue that we accidentally have taken
the superior-lateral superficial inguinal lymph node
with the flap, we preserved all lymph nodes that
we could see to avoid any morbidity and this
isolated lymph node inclusion is not expected to
be responsible for the results that we could achieve.
In this transfer, the whole flap acts as a sponge
which sucks the fluid from the limb ant through it
into its pedicle by its homeostatic activity (Fig. 6).
Uniquely, this case demonstrates the isolated effect
of the vascularized lymphatic vessel transfer because
no other modality was employed and the
patient has not been compliant to compression at
any stage.
Conclusion:
Because of its reasonable results and lower
donor site morbidity, lymphatic vessel only transfer
needs to be studied more and compared with lymph
nodes transfer for cases of advanced lymphedema.
Fig. (4): Ten days post-operative measurements of left lower leg.
Fig. (5): Six months post-operative without compression.
Fig. (6): Sponge action of the flap by day 3 (very swollen
flap and limb deflation begins) the flap lymphatics
power resulted in suction of blood from underneath
resulting in bruises.
Table (1): Pre-operative, 10 days & 6 months postoperative
results of the studied cases.
• Cellulitis
• Lymphorrhea
• Measure 10cm
above medial
malleolus
• Measure 20cm
above medial
malleolus
• Skin tension
and elasticity
Pre-operative
• 1-2 attacks per month
with antibiotic course
every month in
the last 2 years
• Continuous daily
soaking and bad odor
for the last 2 years
• 38cm
• 38cm
• Tense skin lost
elasticity
10 days
postoperative
• NON
• NON
• 33cm
• 33cm
• Improved
• NON
• NON
• 34cm
• 36cm
• Stable
improved
6 months
postoperative
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