Vascularized Lymph Node Flap Transfer (VLNT)

Say Goodbye to Compression Garments after Dr. Cheng’s Lymphedema Microsurgery

For patients with Cheng’s Lymphedema late Grade II to Grade IV lymphedema and no patent functioning lymphatics on indocyanine green (ICG) lymphography, a vascularized lymph node (VLN) flap transfer is recommended for treatment. Patients with Grade IV lymphedema may need liposuction or partial wedge excision, usually one year post VLN flap transfer.

Vascularized Lymph Node Transfer to The Wrist

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How Does It Work?

The choice of VLN flap is based on patient preference for donor site and the availability of sizable lymph nodes assessed by preoperative ultrasonography. Given these factors, the vascularized submental lymph node (VSLN) flap is the most commonly preferred VLN flap by Dr. Cheng’s patients. The VSLN flap is transferred to a distal recipient site- dorsal wrist in the upper extremity or ankle in the lower extremity in accordance with the “pump” mechanism, catchment effect, and natural gravity effect to achieve maximal functional recovery. The unsightly skin on the dorsal wrist or ankle can be excised to form a linear scar one year after the VSLN flap transfer, with the lymphedematous limb becoming softer and smaller.

Intrinsic lymphovenous connections▲ Intrinsic lymphovenous connections exist within the lymph node flap. These connections are responsible for shunting the lymphatic fluid into the venous system, creating local decompression at the site of vascularized lymph node flap transfer.

Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 65.

 
 

FAQS About Lymphatic System and Lymphedema - schema lymphatic system
Data source: Modified figure. Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 219.

Candidates for Vascularized Lymph Node Flap Transfer

  • Lymphedema patients who aggressively receive rehabilitation for more than 6 months without making any improvement or developing episodes of cellulitis
  • Total lymphatic obstruction presents in lymphoscintigraphy.
  • No patent lymphatic (collecting) ducts available at the indocyanine green lymphography for the procedure of lymphovenous anastomosis (LVA). (See LVA section)
  • Cheng’s Grading Ⅱ, Ⅲ and Ⅳ lymphedema

What to Expect After Flap Transfer Surgery

Dr. Cheng’s unique technique by transferring the vascularized lymph node flap to distal recipient site (dorsal wrist) has the best functional improvement regarding to the tissue becoming softer, arm smaller and lighter, less cellulitis, better cosmetic appearance, and most important not need to wear compression garment any more. This is really the improvement of quality of life.

The initial transferred flap in the dorsal wrist is not good looking, but the transferred skin may be removed for achieving better cosmesis at one-year postoperative under local anesthesia. The success rate of the vascularized lymph node flap is 98% in Cheng’s experience. With an average 18 months of follow up after VLNT surgery, 90% of BCRL patients had the improvement with an average circumferential difference improvement of 40%. Varied by individuals, the affected limb, in general, becomes much softer over time; and restriction of daily activities is minimized. Patients resume their normal life styles and retain confidence post operatively.

Case 1
Lymphedema - Before Treatment photo - hands, patient 1 Lymphedema - Before Treatment photo - hands, patient 1
BEFOREAFTER

Before Surgery:

This is a 61-year-old female who had suffered from breast cancer-related lymphedema of the right upper extremity for 10 years after mastectomy, axillary 19 lymph nodes dissection, and radiotherapy. With the combined use of compression garments and the treatment of complete decongestive therapy, she had developed 2 episodes of cellulitis per year.

After Surgery:

At 75- months follow-up, the circumferential reduction rates of the affected limb circumference without the use of compression garments were 100% and 40% above and below the elbow, respectively.

Case 2
Lymphedema - Before Treatment photo - hands, patient 2 Lymphedema - Before Treatment photo - hands, patient 2
BEFOREAFTER

Before Surgery:

A 53-year-old patient with grade II breast cancer-related lymphedema of the right upper extremity for 36 months after modified radical mastectomy, axillary lymph node dissection, and radiation. She developed 2 episodes of cellulitis per year and was refractory to conservative decongestive therapy.

After Surgery:

At 36- months follow-up, the circumferential reduction rates of the affected limb circumference without the use of compression garments were 100% and 85% above and below the elbow, respectively.

Case 3
Lymphedema - Before Treatment photo - hands, patient 3 Lymphedema - Before Treatment photo - hands, patient 3
BEFOREAFTER

Before Surgery:

A 56-year-old patient with grade IV breast cancer-related lymphedema of the left upper extremity for 36 months after modified radical mastectomy, axillary lymph node dissection, and radiation. She developed 5 episodes of cellulitis per year and was refractory to conservative decongestive therapy.

After Surgery:

At 29- months follow-up, the circumferential reduction rates of the affected limb circumference without the use of compression garments were 100% and 65% above and below the elbow, respectively.

Case 4
Lymphedema - Before Treatment photo - hands, patient 4 Lymphedema - Before Treatment photo - hands, patient 4
BEFOREAFTER

Before Surgery:

A 70-year-old patient with grade III breast cancer-related lymphedema of the left upper extremity for 36 months after modified radical mastectomy, axillary lymph node dissection, and radiation. She developed 1 episodes of cellulitis per year and was refractory to conservative decongestive therapy.

After Surgery:

At the 50-months follow-up, the reduction rate was 80% above the elbow and 45% below the elbow without the use of a compression garment.

Evidences of Mechanism of Vascularized Lymph Node Transfer

1. Tc-99m Lymphoscintigraphy Increased Clearance on Static Images

Evidences of Mechanism of Vascularized Lymph Node Transfer, pre-op and post-op 4 monthsStatic views of the same edematous upper limb on posterior view. Images of the upper extremity was taken at 30, 60 and 120 minutes after injection of radio-labelled tracer. Preoperative images (upper row: A-C) and postoperative images (lower row: D-F).In the pre-op images, there is prominent diffuse accumulation of activity shown in the skin of the affected forearm over time. Post-operatively, dermal backflow is less marked in the forearm (D-F) and the radio-labelled tracer has migrated more rapidly to the distal arm (arrow in F).

Data source: Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Lin CH, Ali R, Chen SC, Wallace C, Chang YC, Chen HC, Cheng MH. Plast Reconstr Surg. 2009 Apr;123(4):1265-75.

 

2. Vascularized Groin Lymph Node Transfer to Elbow of Post-op Lymphoscintigraphy

Before and After - 68-year-old female patient who was a victim of right upper limb lymphedema underwent vascularized groin lymph node flap transfer to right elbowA 68-year-old female patient who was a victim of right upper limb lymphedema underwent vascularized groin lymph node flap transfer to right elbow (A). Preoperative lymphoscintigraphy showed accumulation of Tc-99 in the forearm and absence of right axilla lymph node (B). At a follow-up of 56 months, the patient was satisfied with the softening of left upper limb with a circumferential reduction of 58% above elbow and 40% below elbow (C). Post-op lymphoscintigraphy revealed increased uptake of Tc-99 by the transferred vascularized lymph nodes at the elbow level and less accumulation of Tc-99 in right upper arm (D).

Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 204-5.

 

3. Vascularized Submental Lymph Node Transfer to wrist of Post-op Lymphoscintigraphy

Before and After - 52-year-old female patient who was a right upper limb lymphedema underwent vascularized submental lymph node flap transfer to right wristA 52-year-old female patient who was a right upper limb lymphedema underwent vascularized submental lymph node flap transfer to right wrist. Pre-op lymphoscintigraphy showed accumulation of Tc-99 in the forearm and absence of right axilla lymph node. Post-op lymphoscintigraphy revealed increased uptake of Tc-99 by the transferred two vascularized lymph nodes at the wrist level and less accumulation of Tc-99 in right upper arm.

 

4. Intra-op Image

ICG Injection on VLN Flap Edge

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ICG Injection on Lymph Node Directly

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Native Lymph Drainage through VSLN Flap

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Data source: Proposed pathway and mechanism of vascularized lymph node flaps. Ito R, Zelken J, Yang CY, Lin CY, Cheng MH. Gynecol Oncol. 2016 Apr;141(1):182-8.

Contact Dr. Cheng for A Consultation

If you have Breast Cancer Related Lymphedema and would like to know more about the most advanced treatments, contact Dr. Cheng. Internationally recognized as a leading lymphedema specialist, Dr. Cheng can discuss treatment options, based on your individual case. Dr. Cheng is a member of the American Society of Reconstructive Microsurgery has performed numerous VLN surgeries on breast cancer survivors and other lymphedema patients.

 

Lymphedema FAQ
▲The flow diagram represents the impact of both physiologic and nonphysiologic methods of surgical treatment on the lymphatic system.

Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 218.

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