Preliminary outcomes of combined surgical approach for lower extremity lymphedema: supraclavicular lymph node transfer and lymphaticovenular anastomosis

Vascularized lymph node transfer (VLNT) is a well-established surgical approach for treating lower extremity lymphedema (LEL). Since VLNT takes time to show effect, a combined approach with lymphaticovenular anastomosis (LVA) may be more advantageous to patients by inducing an immediate improvement. This study aims to describe our experience and evaluate the results of a combined approach.In this retrospective review, we analyzed a total of 12 patients that underwent simultaneous supraclavicular VLNT and LVA for the treatment of secondary LEL with the ISL stage II or III. Patients who had a follow-up period of less than 12 months were excluded. The supraclavicular flap, including superficial lymphoid tissue as well as deep cervical nodes, was harvested and anastomosed to the posterior tibial vessels. The pre- and postoperative change of circumference difference ratios and LEL index were compared.All twelve flaps survived without re-exploration. An average of 2.3 LVAs were simultaneously performed. At 12.9 months of follow-up (range, 12-16 months), the postoperative mean circumference ratio was significantly improved than pre-operative in 10 cm above the knee (7.9 ± 7.2% vs 15.0 ± 7.6%, p = 0.01), 10 cm below the knee (8.5 ± 7.5% vs 17.4 ± 12.7%, p = 0.03) and lateral malleolus (16.5 ± 15.5% vs 28.6 ± 17.9%, p = 0.03). Also, the mean LEL index was decreased (preoperative 324.3 ± 53.0 vs postoperative 298.0 ± 44.6, p = 0.242) and eight patients showed improvement in LEL stage.The combined approach showed a significant decrease in the circumference of LEL. Additional LVAs could reinforce the effect of a VLNT. Larger series with longer follow-up is needed to confirm our findings.