Recurrent Advanced Lower Extremity Lymphedema Following Initial Successful Vascularized Lymph Node Transfer: A Clinical and Histopathological Analysis

Vascularized lymph node transfer (VLNT) is a physiological approach for the treatment of lymphedema. Despite the reported clinical outcomes of VLNT [1-3], its effectiveness in advanced stages is still unpredictable, with variable outcomes seen among patients. Although donor site morbidity following lymph node flap harvest has been reported [1], significant complications at the recipient site have rarely been reported. Herein, we report an unusual case of recurrent advanced lower extremity lymphedema, after initial successful surgical treatment with a free submental VLNT [3]. A 54-year-old woman underwent bilateral pelvic inguinal lymph node dissection and postoperative radiotherapy for cervical cancer. Thirty-six months later, she presented with advanced secondary lymphedema of the left lower limb and a history of repeated episodes of cellulitis. A submental VLNT to the distal part of the affected limb was performed at another hospital. After six months, a substantial limb volume reduction was noted with no further episodes of cellulitis. Unfortunately, at a 1-year follow up, recurrent swelling of the entire affected limb was observed, which progressively increased in volume proximally to the transferred flap over the next 2 years. At this stage, the patient presented to our hospital for further assessment. Clinically, there was palpable fibrous, indurated tissue and a significant limb volume discrepancy in comparison to the contralateral limb. Surprisingly, the transferred flap demonstrated severe signs of enlargement. In addition, swelling was observed from the flap to the proximal aspect of the limb (Fig. 1). IMAGE