First Do No Harm: Lymph-Sparing Limb Salvage

Secondary lymphedema is a chronic, progressive condition characterized by limb swelling that arises after disruption of lymphatic channels from trauma or iatrogenic injury. In patients with complex soft tissue defects, reconstruction intended to restore the limb may inadvertently disrupt lymphatic drainage, highlighting the need for lymphatic-conscious surgical approaches. We present a retrospective case series of three patients with lower extremity soft tissue injuries who underwent flap-based reconstruction at our institution between 2021 and 2024. Reconstructive techniques, intraoperative decision-making, and postoperative lymphatic outcomes were analyzed over a follow-up period of 11 to 38 months. In the first two cases, disruption of established or new lymphatics during flap inset or repeated flap re-elevations may have contributed to the development of lymphedema. By contrast, indocyanine green (ICG) lymphography-guided flap planning and inset in the third case preserved lymphatic drainage pathways which could potentially lead to the development of lymphedema. Post-traumatic flap-based extremity reconstruction requires careful attention to native and transferred lymphatics to decrease the risk of secondary lymphedema. These cases draw attention to the concepts of preserving lymphatics, maintaining lymphatic axiality, and using ICG lymphography when planning flap-based reconstruction.