Physiological restoration of lymphatic flow in Posttraumatic extremity lymphedema using lymphatic flaps.

Background: Posttraumatic lymphedema is poorly discussed in literature. Flap reconstruction considering its lymphatic- axiality has been reported in preventing lymphedema development following trauma or sarcoma excision. In this study we report the results of utilizing lymphatic flaps in treatment of established posttraumatic lymphedema.

Methods: This was a retrospective study of 74 patients (60 lower limbs and 14 upper limbs) with posttraumatic lymphedema that underwent simultaneous soft tissue and lymphatic reconstruction using lymphatic skin flaps. The primary endpoint was providing stable soft tissue coverage and change in limb volume. Secondary endpoints were changes in lymph flow using both lymphoscintigraphy and ICG lymphography.

Results: SCIP flap was used in 46 cases (62.2%), anterolateral thigh (ALT) flap in 14 cases (18.9), superficial inferior epigastric artery (SIEA) flap in 9 cases (12.2%), and deep inferior epigastric artery perforator (DIEAP) flap in 5 cases (6.8%). End (vein)- to- side (lymphatic) LVA was successfully performed in 21 cases (28.4%). During follow-up, significant change in volume was noted in all patients. Using ICG lymphography, lymphatic flow through the flaps was revealed in 59.5% of patients. No lymphatic flow within the flap was observed in 30 cases (40.5%). While qualitative lymphoscintigraphy showed significant changes in the parameters including improved symmetry in the uptake of Technitium99 nanocolloids (89.2%), visualizing the proximal draining lymph nodes and major lymphatic ducts, and improvement in the dermal backflow.

Conclusion: Lymphatic skin flaps allow simultaneous soft tissue and lymphatic reconstruction. Scar excision at the affected limb, flap selection and insetting based on ICG navigation at both the recipients and donor sites is important for successful flap integration and spontaneous lymphatic communications.