A 72-year-old female was referred to our lymphedema clinic with a twenty-six-year history of bilateral lower extremity lymphedema. The patient had lymphedema in both extremities, which was more severe in the left lower extremity (International Society of Lymphology stage 3) than in the right lower extremity (International Society of Lymphology stage 2). She first noticed the signs and symptoms of lymphedema after radiation therapy. She complained of severe left lower extremity heaviness and pain, difficulty in ambulation, and recurrent cellulitis and intermittent sepsis that required hospitalization. She underwent combination treatment including decongestive physiotherapy for years, daily manual and mechanical lymphatic drainage, and compression garments. However, the nonsurgical management of lymphedema did not significantly improve the swelling and associated symptoms. The patient had a history of lymphoma and treated with radiation therapy on right inguinal area. The patient did not have a history of diabetes mellitus or hypertension according to the complete patient medical history.
The severity of the vascularity was measured by the ankle-brachial index and partial transcutaneous partial oxygen tension. The patient had a decreased ankle-brachial index in both extremities and the transcutaneous partial oxygen tension on the left lower extremity was 8 mmHg. The lower extremity computed tomography angiography identified severe stenosis of the bilateral superficial femoral artery. Furthermore, a left peroneal artery in the lower extremity was completely occluded below the knee. Percutaneous transluminal angiography was recommended but the patient strongly refused. Indocyanine green (ICG) fluorescence lymphography showed severe dermal backflow in the entire extremity including the foot and no lymphatic vessels were visualized on her left lower extremity with severe lymphedema. However, magnetic resonance lymphangiography showed some functioning lymphatic vessels were identified in the lower extremity with severe lymphedema. Therefore, we planned simultaneous LVA and VLNT for the left extremity that had severe lymphedema for 26 years and we provided detailed information on the donor sites except for the contralateral groin flaps including inguinal lymph nodes due to the high risk of aggravating the contralateral lower extremity lymphedema. The patient selected supraclavicular lymph node transfer and LVA and underwent surgery.
The ICG lymphography, lymphoscintigraphy, and magnetic resonance lymphangiography were performed before surgery (Fig. 1). A milliliter of ICG mixed with 2% lidocaine was injected subcutaneously at the second web space of the affected extremity at the bedside. The fluorescence images of the lymphatic vessels were obtained with a near-infrared camera (Moment K; IANC&S, Seoul, Korea), and the functioning lymphatic vessels were marked. The functioning lymphatic vessels were not identified in the patient using the ICG lymphography and magnetic resonance lymphangiography was used to identify the functional lymphatic vessels for LVA. For supraclavicular VLNT, surface marking was made to form a triangle of the external jugular vein laterally, the lateral border of the sternocleidomastoid (SCM) muscle medially, and the clavicle inferiorly, containing supraclavicular lymph nodes to be harvested.
The circumference of the affected and unaffected lower extremity was measured using a standardized measuring tape. The circumference of both the affected/unaffected extremities was measured in six places, 15 cm above the knee, 10 cm above the knee, at the knee (popliteal crease as the reference point as relevant), 10 cm below the knee, 15 cm below the knee, and a the ankle. The circumference difference ratio was calculated according to the formula: (circumference of affected extremity – circumference of unaffected extremity) / circumference of unaffected extremity x 100. The volume of the extremity was also calculated based on the circumference measures. The volume segment was measured according to the formula of a truncated cone: V = π x h x (R2 + r2 + Rr) / 3 where π is a constant, h is the height, R is the radius on base, and r is the radius on top [7, 8]. The circumferences of the extremity was measured 10 cm above the knee and 10 cm below the knee was used to calculate the volume segment. The volume of the unaffected extremity was also measured and the volume difference ratio was ultimately calculated according to the formula: (volume of affected extremity – volume of unaffected extremity) / volume of unaffected extremity x 100 .
The VLNT surgery was performed first, followed by the LVA. Under general anesthesia, the patient was in the supine position with her head tilted 45° away from the right side of the harvest. A 5 cm skin incision was made 2 cm above the clavicle, and the omohyoid muscle near the SCM muscle was identified, dissected, and retracted using a rubber loop. Dissection of the supraclavicular flap proceeded carefully medially to laterally underneath the SCM muscle. The external and internal jugular vein and carotid artery were identified and meticulous dissection was performed to prevent massive bleeding. All submuscular fat including the lymph nodes were included in the flap with careful retraction of the external and internal jugular vein and carotid artery. The transverse cervical (TC) artery and vein were identified and dissected from the lateral to medially until the thyrocervical trunk was identified. After dissection of the TC pedicle, the supraclavicular flap was elevated from the anterior scalene muscle. The phrenic nerve, supraclavicular nerve, and right lymphatic duct were not injured. Once the flap elevation was done, the recipient vessels were identified using a Doppler and dissected. The TC pedicle was ligated, and the flap was transferred to the recipient site of the affected extremity. End-to-side anastomosis using 9 − 0 and 10 − 0 nylon sutures was performed for transplantation. Flap survival was confirmed by Doppler and flap bleeding in the visual field.
After the VLNT surgery, two to three lymphatic vessels were used for microsurgical anastomosis to the adjacent veins for LVA. Intraoperatively, two to three 3-cm longitudinal incisions were made under a surgical microscope according to the preoperative mapping based on the result of the magnetic resonance lymphangiography. After the superficial fascia incision, functioning lymphatic vessels were identified deep to the superficial fascia and one to two functional lymphatic vessels were anastomosed to the adjacent veins using 11 − 0 nylon sutures. Functional drainage was confirmed by washout of the venous blood in the anastomosed vein (Fig. 2).
Antibiotics were administered to prevent surgical site infection. The affected extremity was compressed and elevated immediately postoperatively and postoperative compression bandage therapy with 35 to 40 mmHg pressure was instituted for at least six months following surgery.
Three months after surgery, the patient had a significant volume reduction in the left lower extremity, which was obvious in her feet and lower leg. Her left lower extremity symptoms of heaviness and pain decreased. She had improved ambulation and required a lighter level of compression garments.
The circumference difference ratios before surgery were 29, 28, 34, 29, 34, and 32% at the levels of 15 cm above the knee, 10 cm above the knee, at the knee (popliteal crease), 10 cm below the knee, 15 cm below the knee, and at the ankle. The ratios were decreased to 25, 23, 18, 15, 14, and 16% at the levels, respectively. The volume difference ratio was also decreased from 48 to 23%. The patient had significant the circumference and volume reduction of the left lower extremity (Fig. 3). Symptoms related to lymphedema improved following VLNT performed synchronously with LVA.