Vascularized Lymph Node Transfer to the Profunda Artery Perforator Pedicle: A Reliable Proximal Recipient Vessel Option in the Medial Thigh

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Vascularized lymph node transfer has been successfully used to treat lower extremity lymphedema using a variety of recipient-site options.1–3 There are circumstances where vascularized lymph node transfer to the proximal medial thigh may be preferable, such as patients with recurrent cellulitis and swelling in this region or patients having two vascularized lymph node transfers to the thigh and lower leg. In addition, the superficial lymphatic collectors course through this region, where they can potentially network with the vascularized lymph node transfer. The profunda artery perforator flap has been described for breast and head and neck reconstruction, with the major benefit of having a long, large-caliber pedicle length.4,5 Although it has not yet been described as a recipient vessel option for vascularized lymph node transfer, it has become our primary choice for proximal vascularized lymph node transfer to the lower extremity. Exposure of the profunda artery perforator pedicle is rapid, and the artery and vein are significantly larger than the neighboring gracilis pedicle. The longer pedicle ensures subcutaneous placement of the vascularized lymph node transfer and the larger vein minimizes venous outflow resistance.
The patient is placed in the frogleg position and an incision is made along the posterior border of the adductor longus muscle prominence, avoiding the greater saphenous vein. A posterior branch of the saphenous vein is divided, maintaining length on this branch as an option for venous anastomosis. The adductor longus muscle fascia is incised, exposing both the gracilis and profunda artery perforator pedicles (Fig. 1). The profunda artery perforator pedicle is always inferior to the gracilis pedicle and significantly larger. The pedicle may be in plain view directly on the adductor magnus muscle or often is intramuscular within the adductor magnus. A brief course of intramuscular dissection posterior to the gracilis muscle may be required to increase its length. The authors typically excise a portion of subcutaneous fat and fascia to accommodate the lymph node inset (Fig. 2). After anastomosis, the flap is secured in the subcutaneous plane or can be tunneled anteriorly into the region of the femoral triangle if desired. Layered closure is performed over a closed suction drain.
Postoperatively, patients remain on bedrest, in a slight frogleg position, for 2 days. They are out of bed to a chair on postoperative day 3, with ambulation beginning on postoperative day 4. In our early experience, we have not noted any recipient-site–related complications.
Alternative recipient vessel options have been described in the femoral triangle and in the knee region. However, the superficial circumflex iliac artery or superficial inferior epigastric artery can be small and may not be available. The saphenous artery is also small and more distal. As our understanding of lymphatic disease and vascularized lymph node transfer continue to evolve, recipient-site selection may become an increasingly important component of surgical strategy. The profunda artery perforator pedicle provides a reliable large caliber option for proximal lymph node transfer in the lower extremity.
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