The Incidence of Donor-Site Morbidity after Transverse Cervical Artery Vascularized Lymph Node Transfers

Sir: Surgical treatment for lymphedema is expanding at a rapid pace. The following case demonstrates a critical need for communication between surgeons, whether they are invested in microsurgical techniques or debulking liposuction. A 57-year-old woman with bilateral lower extremity primary lymphedema tarda underwent a right transverse cervical artery vascularized lymph node transfer to the left lower extremity (the first surgeon was Marga F. Massey, M.D.; the second surgeon is not identified but was in an independent practice in a different state than Dr. Massey). Her preoperative lymphoscintigram (Fig. 1, left) demonstrated no lymph node tracer uptake in either groin. Eight months after surgery, the patient presented with intermittent mild right arm swelling. Repeated lymphoscintigraphy showed no tracer uptake in the right axilla (ipsilateral to the cervical donor site) and a new finding of tracer uptake in the nonoperative right inguinal region (Fig. 1, right). The patient was subsequently lost to in-person follow-up after having related dissipation of her right arm swelling by means of several follow-up phone consultations.Fig. 1: (Left) Lymphoscintigram of the patient obtained preoperatively, 4 hours after injection before right transverse cervical artery vascularized lymph node transfer to the left groin for left lower extremity lymphedema tarda. Bilateral axillary regional lymph node uptake of tracer is denoted by the red arrow, suggesting normal anatomy and function of the upper extremities. Lack of bilateral inguinal uptake is denoted by the green arrow and is consistent with her clinical presentation. (Right) Lympho scintigram of the patient 8 months postoperatively, 4 hours after injection. The red arrow highlights a lack of right axillary tracer uptake. This combined with new right arm dermal backflow (blue asterisk) correlates with the postoperative presentation of right upper extremity lymphedema believed to be iatrogenic. New right inguinal tracer uptake is denoted by the green arrow. This finding begs further investigation of variable imaging techniques versus a dynamic physiologic state of primary lymphedema tarda. No tracer uptake is noted in the location of the vascularized lymph node transfer in the left groin, which is consistent with prior published reports, that only 30 percent of vascularized lymph node transfers take up tracer despite clinical improvement of lymphedema (Becker C, Assouad J, Riquet M, Hidden G. Postmastectomy lymphedema: Long-term results following microsurgical lymph node transplantation. Ann Surg. 2006;243:313–315).Approximately 18 months after transverse cervical artery vascularized lymph node transfer, the patient presented to a second surgeon requesting debulking liposuction of the left leg. Right arm swelling was noted on physical examination by the second surgeon. A third lymphoscintigram was obtained (not shown). No tracer uptake was demonstrated in either groin or in the right axilla (these results were reported in an abstract presentation by the second surgeon at the National Lymphedema Network Annual Meeting in Washington, D.C., in September of 2014). She reportedly underwent uneventful left lower extremity liposuction debulking performed by the second surgeon without any contact with the initial surgeon, thus leaving the initial surgeon unaware of the progression of the donor-site morbidity. This communication relates the first reported case of iatrogenic upper extremity lymphedema from a transverse cervical artery vascularized lymph node transfer. Teaching has focused on the potential risk of secondary lymphedema of the head and neck in the setting of a supraclavicular flap harvest. This case highlights the need for the use of ipsilateral upper extremity reverse lymphatic mapping when using a cervical approach.1,2 Furthermore, this case illustrates variability in the quality of lymphoscintigraphic imaging versus a putative dynamic presentation of primary lymphedema. Review of the three sequential lymphoscintigrams of the nonoperative right lower extremity revealed an illusive appearance of inguinal regional lymph nodes only on the second study. Such variability begs further investigation.3 This case demonstrates the importance of coordinated care and collection of outcomes data in the expanding field of lymphatic reconstruction. Because lymphedema patients are often moving from surgeon to surgeon hoping for a surgical cure for this chronic, debilitating disease, it is not uncommon for patients to be lost to in-person clinical follow-up. Therefore, it is imperative that we as surgeons develop a system within Health Insurance Portability and Accountability Act guidelines that allows tracking of patient-centered outcomes and morbidity. I would call on the American Society of Plastic Surgeons to initiate a patient registry for the surgical treatment of lymphedema to track patient outcomes and morbidity. Surgeon participation in a national registry would result in total transparency and an improvement in the quality of care for this high-risk patient population. DISCLOSURE Dr. Massey is on the Medical Advisory Board of the National Lymphedema Network. The authors have no commercial associations that pose a potential conflict of interest. Marga F. Massey, M.D., C.L.T. The National Institute of Lymphology, Chicago Dhanesh K. Gupta, M.D. Northwestern University Feinberg School of Medicine Chicago, Ill.