Combined lymphovenous anastomosis and deep inferior epigastric perforator flap with lymphatic tissue preservation for defect reconstruction and lymphedema‐lymphocele prevention after medial thigh sarcoma resection: A case report

Abstract

Soft tissue sarcomas are a rare group of malignant tumors that often require an extensive surgical resection to be safely treated. When they are localized in the upper medial thigh, this treatment inevitably leads to large defects frequently causing a series of early and late postoperative complications. Among these, lymphocele and lymphedema are rather common and should try to be avoided. Many solutions with a demonstrated efficacy have been described for this purpose after groin dissection procedure, ranging from lymphovenous anastomosis to pedicled or free flaps. Anyway, there is much less information regarding the medial thigh. Here we present a case of resected sarcoma involving the adductors compartment reconstructed using a pedicled deep inferior epigastric (DIEP) flap with lymphatic tissue transfer, combined with preventive lymphovenous anastomosis (LVA) performed at the superior‐edge‐of‐the‐knee incision (SEKI) point. A 58‐year‐old patient presented a 10 cm × 12 cm soft tissue defect after margin free sarcoma removal. To fill this defect, we harvest a 24 × 9 cm pedicled DIEP flap conserving its lymphatic vessels running from the upper margin to the right groin lymphnodes. Then we rotated it maintaining the lymphnodes in their original site and moved it through an inguinal tunnel in the area of the defect. The distal part was de‐epithelized and folded down to cover the deeper region. The postoperative course was uneventful and at the 6 months follow up the patient showed a good outcome with no swelling and no signs of tumor relapse. This result therefore may suggest that this kind of combined treatment might be an effective technique to prevent all those complications linked to the impairment of lymphatic system drainage in the proximal medial thigh.

Combined pedicled superficial circumflex iliac artery perforator (SCIP) flap with lymphatic tissue preservation and lymphovenous anastomosis (LVA) for defect reconstruction and lymphedema–lymphocele prevention in thigh sarcoma surgery: Preliminary results

“…Considering the good outcomes obtained by means of these treatments (VLVT and LVA), we had the idea of combining both the procedures in order to emphasize their efficacy. To the best of our knowledge no previous studies have been done resorting to this technique with the only exception of a case report recently submitted by us that gave a successful result 28 . On this basis, we present a preliminary study that seems to confirm the validity of this solution.…”

“…To the best of our knowledge no previous studies have been done resorting to this technique with the only exception of a case report recently submitted by us that gave a successful result. 28 On this basis, we present a preliminary study that seems to confirm the validity of this solution. In particular, it demonstrates its efficacy for the reconstruction of the medial thigh defect and, more interestingly, for the prevention of complications related to the damaged lymphatic vessels.…”

Reply to: Lymph interpositional flap transfer for upper thigh soft tissue and lymphatic reconstruction without lymphovenous anastomosis

“…It also provides a rich lymphatic network that can be used as a lymph interposition flap as we already showed in a previous case report. 3 Concerning the indocyanine green lymphography navigation, we confirm its serious importance during both the planning and the elevation of the flap. It allows us to visualize the lymph pathway and it helps to preserve the vessels during the harvest.…”

Total groin defect reconstruction by lymphatic flow‐through (LyFT) pedicled deep inferior epigastric artery perforator (DIEP) flap resorting to its superficial veins for lymphovenous anastomosis (LVA): A case report

“…Lymphatic tissue transfer, instead, has less evidence but it is still a fascinating option. It consists in preserving the natural lymphatic network present in the donor tissue of the flap that will be then moved into the damaged area, offering a new route for lymph drainage (Scaglioni, Meroni, Franchi, & Fritsche, 2020b).…”