Flow-through Omental Flap for Vascularized Lymph Node Transfer: A Novel Surgical Approach for Delayed Lymphatic Reconstruction

Vascularized lymph node transfer (VLNT) has emerged as a promising surgical approach for the treatment of chronic lymphedema (LE), associated with both quantitative and subjective improvements.1 However, there remain concerns regarding its potential to cause donor-site LE, which has been described in 1.3%–23.1% of patients.2,3 The use of the omentum for VLNT has increased in popularity due to its angiogenic and immunologic properties.4 Further, it has no risk of donor-site LE.5 However, a remaining concern with the omental flap is its association with intra-flap venous hypertension. A single arterial and venous anastomosis for the omental flap has been reported to increase the risk of venous hypertension.6 To relieve venous congestion, techniques such as venous supercharging or the creation of an intra-flap arteriovenous fistula have been proposed.4,6 However, technical modifications to facilitate an optimal pressure gradient to maintain adequate lymph perfusion have not been determined. The addition of a distal arterial anastomosis has the potential to offload potential venous congestion by creating a better arteriovenous flap gradient. In this paper, we aim to propose a novel surgical technique to decrease venous hypertension and describe our initial experience using the omentum as a flow-through flap for the treatment of patients with chronic breast cancer-related lymphedema (BCRL).