Download PDF
J Reconstr Microsurg 2016; 32(08): 625-631
DOI: 10.1055/s-0036-1584527
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The Venous Lymph Node Flap: Concepts, Experimental Evidence, and Potential Clinical Implications

Giuseppe Visconti
1   Centre for Surgical Treatment of Lymphedema, Department of Plastic and Reconstructive Surgery, Catholic University of “Sacro Cuore,” University Hospital “A. Gemelli,” Rome, Italy
2   Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
,
Thomas Constantinescu
2   Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
3   Division of Plastic and Reconstructive Surgery, Humber River Hospital, Toronto, Ontario, Canada
,
Pei Yu Chen
4   Department of Histopathology and Cytodiagnosis, China Medical University Hospital, Taichung, Taiwan
,
Marzia Salgarello
1   Centre for Surgical Treatment of Lymphedema, Department of Plastic and Reconstructive Surgery, Catholic University of “Sacro Cuore,” University Hospital “A. Gemelli,” Rome, Italy
,
Gianluca Franceschini
5   Breast Unit, Catholic University of “Sacro Cuore,” University Hospital “A. Gemelli,” Rome, Italy
,
Riccardo Masetti
5   Breast Unit, Catholic University of “Sacro Cuore,” University Hospital “A. Gemelli,” Rome, Italy
,
Hung-Chi Chen
2   Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
› Author Affiliations
Further Information

Publication History

10 December 2015

12 May 2016

Publication Date:
21 June 2016 (online)

    Permissions and Reprints

Abstract

Background Traditionally, lymph node flaps (LNF) have been designed as arteriovenous flaps, with little attention given to the functional anatomy of lymphatic system included in the flap. Based on the anatomical and physiological features of lymphatic system, we believe that a new concept of LNF, the venous LNF, should be investigated. In this article, we report the concepts and findings of venous LNF, and help gauge its potential clinical application in the treatment of lymphedema.

Methods Eight healthy Wistar rats underwent cervical LNF harvesting along the right external jugular vein, right inguinal node clearance, and venous LNF transfer in a flow-through fashion along the femoral vein. At 45 postoperative days, the restoration of lymphatic continuity with surrounding tissue was verified with intradermal injection of 0.1% of methylene blue. The flaps were then excised and sent for histologic evaluation.

Results All rats survived uneventfully in the postoperative period and no postoperative complications were experienced. The venous anastomosis was proven to be patent clinically. In all rats we found reestablishment of lymphatic continuity with surrounding tissues. Histologically, the nodes showed the following main histoarchitectural changes: drastic reduction of the stromal compartment and preservation of the lymphatic/sinus and vascular compartments.

Conclusions The novel venous LNF flap is able to restore lymphatic continuity with surrounding tissue. As healing occurs, the lymph nodes undergo major histoarchitectural changes. The venous LNF has unique theoretical advantages over arteriovenous LNFs. Further investigations would be beneficial to understand its potential in the surgical treatment of lymphedema.

Keywords

lymph node transfer - lymphedema - lymphatic surgery

Disclosure

None of the authors has a financial interest in any of the products, devices, or drugs mentioned in the article.


 

  • References

  • 1 O'Brien BM, Mellow CG, Khazanchi RK, Dvir E, Kumar V, Pederson WC. Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema. Plast Reconstr Surg 1990; 85 (4) 562-572
    CrossrefPubMedGoogle Scholar
  • 2 Becker C. Autologous Lymph Node Transfers. J Reconstr Microsurg 2016; 32 (1) 28-33
    PubMedGoogle Scholar
  • 3 Mehrara BJ, Zampell JC, Suami H, Chang DW. Surgical management of lymphedema: past, present, and future. Lymphat Res Biol 2011; 9 (3) 159-167
    CrossrefPubMedGoogle Scholar
  • 4 Yamamoto T, Narushima M, Yoshimatsu H , et al. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg 2014; 72 (1) 67-70
    CrossrefPubMedGoogle Scholar
  • 5 Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg 2014; 133 (4) 905-913
    CrossrefPubMedGoogle Scholar
  • 6 Akita S, Mitsukawa N, Kuriyama M , et al. Comparison of vascularized supraclavicular lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity lymphedema. Ann Plast Surg 2015; 74 (5) 573-579
    CrossrefPubMedGoogle Scholar
  • 7 Cheng MH, Chen SC, Henry SL, Tan BK, Lin MC, Huang JJ. Reply: Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: the flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg 2014; 133 (3) 428e-429e
    PubMedGoogle Scholar
  • 8 Cheng MH, Huang JJ, Nguyen DH , et al. A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle. Gynecol Oncol 2012; 126 (1) 93-98
    CrossrefPubMedGoogle Scholar
  • 9 Barreiro GC, Baptista RR, Kasai KE , et al. Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use. J Reconstr Microsurg 2014; 30 (6) 389-396
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Sapountzis S, Singhal D, Rashid A, Ciudad P, Meo D, Chen HC. Lymph node flap based on the right transverse cervical artery as a donor site for lymph node transfer. Ann Plast Surg 2014; 73 (4) 398-401
    CrossrefPubMedGoogle Scholar
  • 11 Cheng MH, Huang JJ, Wu CW , et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg 2014; 133 (2) 192e-198e
    CrossrefPubMedGoogle Scholar
  • 12 Patel KM, Lin CY, Cheng MH. From theory to evidence: long-term evaluation of the mechanism of action and flap integration of distal vascularized lymph node transfers. J Reconstr Microsurg 2015; 31 (1) 26-30
    PubMedGoogle Scholar
  • 13 Visconti G, Brunelli C, Mulè A , et al. Septum-based cervical lymph node free flap in rat: a new model. J Surg Res 2016; 201 (1) 1-12
    CrossrefPubMedGoogle Scholar
  • 14 Hadamitzky C, Blum KS, Pabst R. Regeneration of autotransplanted avascular lymph nodes in the rat is improved by platelet-rich plasma. J Vasc Res 2009; 46 (5) 389-396
    CrossrefPubMedGoogle Scholar
  • 15 Schindewolffs L, Breves G, Buettner M, Hadamitzky C, Pabst R. VEGF-C improves regeneration and lymphatic reconnection of transplanted autologous lymph node fragments: An animal model for secondary lymphedema treatment. Immun Inflamm Dis 2014; 2 (3) 152-161
    CrossrefPubMedGoogle Scholar
  • 16 Sommer T, Buettner M, Bruns F, Breves G, Hadamitzky C, Pabst R. Improved regeneration of autologous transplanted lymph node fragments by VEGF-C treatment. Anat Rec (Hoboken) 2012; 295 (5) 786-791
    CrossrefPubMedGoogle Scholar
  • 17 Tobbia D, Semple J, Baker A, Dumont D, Johnston M. Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema. Plast Reconstr Surg 2009; 124 (3) 777-786
    CrossrefPubMedGoogle Scholar
  • 18 Goldschlager R, Rozen WM, Ting JW, Leong J. The nomenclature of venous flow-through flaps: updated classification and review of the literature. Microsurgery 2012; 32 (6) 497-501
    CrossrefPubMedGoogle Scholar
  • 19 Mihara M, Hara H, Furniss D , et al. Lymphaticovenular anastomosis to prevent cellulitis associated with lymphoedema. Br J Surg 2014; 101 (11) 1391-1396
    CrossrefPubMedGoogle Scholar
  • 20 Quéré I. Lymphatic system: Anatomy, histology and physiology [in French]. Presse Med 2010; 39 (12) 1269-1278
    CrossrefPubMedGoogle Scholar
  • 21 International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013; 46 (1) 1-11
    PubMedGoogle Scholar
  • 22 Swartz MA. The physiology of the lymphatic system. Adv Drug Deliv Rev 2001; 50 (1–2) 3-20
    CrossrefPubMedGoogle Scholar
  • 23 Margaris KN, Black RA. Modelling the lymphatic system: challenges and opportunities. J R Soc Interface 2012; 9 (69) 601-612
    CrossrefPubMedGoogle Scholar
  • 24 Sacchi G, Weber E, Aglianò M, Raffaelli N, Comparini L. The structure of superficial lymphatics in the human thigh: precollectors. Anat Rec 1997; 247 (1) 53-62
    CrossrefPubMedGoogle Scholar
  • 25 Boggon RP, Palfrey AJ. The microscopic anatomy of human lymphatic trunks. J Anat 1973; 114 (Pt 3) 389-405
    PubMedGoogle Scholar
  • 26 Ohhashi T, Azuma T, Sakaguchi M. Active and passive mechanical characteristics of bovine mesenteric lymphatics. Am J Physiol 1980; 239 (1) H88-H95
    PubMedGoogle Scholar
  • 27 Zawieja DC, Davis KL, Schuster R, Hinds WM, Granger HJ. Distribution, propagation, and coordination of contractile activity in lymphatics. Am J Physiol 1993; 264 (4 Pt 2) H1283-H1291
    PubMedGoogle Scholar
  • 28 Schmid-Schönbein GW. Microlymphatics and lymph flow. Physiol Rev 1990; 70 (4) 987-1028
    PubMedGoogle Scholar
  • 29 Browse NL, Doig RL, Sizeland D. The resistance of a lymph node to lymph flow. Br J Surg 1984; 71 (3) 192-196
    CrossrefPubMedGoogle Scholar
  • 30 Papp M, Makara GB, Hajtman B. The resistance of in situ perfused lymph trunks and lymph nodes to flow. Experientia 1971; 27 (4) 391-392
    CrossrefPubMedGoogle Scholar
  • 31 Willard-Mack CL. Normal structure, function, and histology of lymph nodes. Toxicol Pathol 2006; 34 (5) 409-424
    CrossrefPubMedGoogle Scholar
  • 32 Young B, O'Dowd G, Woodford P. Wheater's Functional Histology: A Text and Colour Atlas. 6th ed. 2014: 207-214 . Chap 11
    Google Scholar
  • 33 Tümer A, Oztürk-Demir N, Basar-Eroğlu C, Noyan A. Spontaneous contractions and stretch-evoked responses of isolated lymph nodes. J Muscle Res Cell Motil 1983; 4 (1) 103-113
    CrossrefPubMedGoogle Scholar
  • 34 Hughes GA, Allen JM. Neural modulation of bovine mesenteric lymph node contraction. Exp Physiol 1993; 78 (5) 663-674
    CrossrefPubMedGoogle Scholar
  • 35 Visconti G, Constantinescu T, Chen HC. The venous lymph-node flap. Microsurgery 2015; (e-pub ahead of print). doi: 10.1002/micr.22477
    PubMedGoogle Scholar
  • 36 Visconti G, Constantinescu T, Araki J, Salgarello M, Chen HC. The venous lymph node flap for the treatment of peripheral lymphedema: Preliminary evidence. Microsurgery 2016; (e-pub ahead of print). doi: 10.1002/micr.30036
    PubMedGoogle Scholar