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Avoiding A Skin Paddle In Heterotopic Vascularized Lymph Node Transfer To The Distal Lower Extremity
Erez Dayan, M.D.1, Joseph H. Dayan, M.D2, Mark L. Smith, M.D.1.
1Mount Sinai Beth Israel, New York, NY, USA, 2Memorial Sloan Kettering, New York, NY, USA.

Purpose
Heterotopic Vascularized Lymph Node Transfer (HVLNT) to the ankle has been successfully used for secondary lower extremity lymphedema. Unfortunately, the limited skin laxity around the ankle necessitates a skin paddle for flap insetting and results in an unsightly mass. In an effort to avoid the skin paddle but keep the lymph nodes below the knee, we have used the medial calf as a recipient site for HVLNT.
Method
14 patients with lower extremity lymphedema underwent preoperative imaging to identify recipient vessels. A longitudinal incision was made over the upper medial calf and dissection continued down to the muscle fascia. Exploration for a perforating vessel to the skin was performed through the muscle to the source vessels. HVLNT was then performed.
Results
In 13/14 patients, the medial sural vessels were visible on MRA and were used for lymph node transfer. This represents the largest series of free tissue transfers to the medial sural vessels in the literature. In the one patient where neither the medial sural vessels nor its perforators to the skin were seen on MRA, a single dominant perforator to the skin was seen laterally between the heads of the gastrocnemius muscle. 
Conclusion
Using the medial calf as a recipient site in HVLNT allows distal placement of the flap while avoiding a bulky skin paddle. It also places the flap in proximity to lymphatics that accompany the saphenous vein. The location in the medial calf avoids pressure on the flap in the early post-operative period.


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