A Practical Algorithm for Donor- and Recipient-site Selection in Vascularized Lymph Node Transfer in Extremity Lymphedema

Background: Vascularized lymph node transfer (VLNT) involves the autologous transplantation of functioning lymph nodes to a lymphedematous region. Despite various donor and recipient sites, comparative effectiveness and complication rates remain understudied. This study aims to develop an evidence-based algorithm for donor- and recipient-site selection in VLNT. Methods: A prospectively maintained database was reviewed for patients who underwent unilateral VLNT for chronic extremity lymphedema between January 1, 2016, and December 31, 2023. Surgical effectiveness was assessed using circumferential limb measurements over time. Complications were graded according to the Clavien-Dindo classification. Results: Among 161 patients, donor sites included groin (n = 129, 80.1%), lateral thoracic (n = 16, 9.9%), mesenteric (n = 13, 8.1%), and omental (n = 3, 1.9%) flaps, all of which demonstrated comparable long-term effectiveness. For upper extremity lymphedema, axillary placement (n = 125, 94.7%) resulted in faster and greater volume reductions than distal forearm placement (n = 6, 4.5%). For lower extremity lymphedema, lower leg placement (n = 18, 62.1%) was more effective than the groin (n = 10, 31.0%). Waterjet-assisted liposuction provided transient improvements only, without long-term benefits. Complications occurred in 14 (8.7%) patients and were exclusively observed after groin-based (n = 12, 9.1%) or thoracic-based VLNTs (n = 2, 6.9%). Conclusions: Donor-site selection should prioritize minimizing morbidity, given their comparable long-term effectiveness. In contrast, recipient-site selection significantly impacts outcomes, with axillary and lower leg placements demonstrating greater effectiveness. Scar tissue release may have a more influential role in VLNT outcomes than previously recognized.