Flow-Through Omental Flap for Vascularized Lymph Node Transplant in Lymphatic Reconstruction
Miguel G. Bravo, MD, Anna R. Johnson, MPH, John F. Critchlow, MD, Bernard T. Lee, MD MBA MPH, Dhruv Singhal, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
PURPOSE: The vascularized omental free flap has been described as a reliable option for the treatment of peripheral lymphedema. However, the flap is a high-pressure system that may require venous supercharging or intra-flap AV fistula in order to offload the arterial inflow. The aim of this study is to introduce and present our experience using a flow-through omental flap as a novel approach to minimize the arterial inflow while maximizing venous outflow.
METHODS: A retrospective review of a prospectively maintained quality improvement (QI) database was performed. Consecutive patients with unilateral breast-cancer related lymphedema (BCRL) who underwent delayed lymphatic reconstruction using a flow through omental free flap were identified. Patient characteristics and intraoperative specifics were retrieved.
RESULTS:Five consecutive patients underwent a free omental flap by a single surgeon from January 2018 to September 2018. All patients were female with a mean age of 59.6 (41-73) years and BMI of 28.8 (25.1-32.3) kg/m2. All patients were classified with stage II lymphedema using the International Lymphedema Staging (ILS) criteria. Mean flap weight was 30 (22-40) grams and mean number of lymph nodes transferred detected by intraoperative ultrasound was 7.6 (6-11). In all patients, the right gastroepiploic artery and vein were anastomosed to the proximal end of the radial artery and to one vena comitante, respectively. An anastomosis of the distal end of the radial artery to the left gastroepiploic artery was performed. The intervening segment of the native radial artery was removed. The flap was then supercharged by anastomosing the left gastroepiploic vein to the cephalic vein. All patients followed the standard protocol for postoperative care at our institution. There were no flap losses or peri-operative complications.
CONCLUSION: The flow-through omental free flap to the forearm should be considered as a reliable surgical option for patients with upper extremity BCRL. A distinct advantage of this inset includes moderating the arterial in-flow into the inherent high-pressure environment of the omental flap to avoid an inflow-outflow mismatch. Further study is needed to validate this technique in a larger study sample with longer follow-up.
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