Bridging Lymphatic Vessel Defects with a Perforator Flap that Contains Retrograde Axial Lymphatic Flow

Axiality of lymphatic flow is possibly an important consideration for stimulating recanalization of flow between the transferred flap and the recipient site during wound healing. Antegrade lymphatic flow reconstruction has previously been reported. Here we report the first case where lymph stasis following groin lymph nodes dissection could be recanalized in a pedicled anterolateral thigh flap in which the collecting lymphatics were arranged retrograde. A 78-year-old male patient presented with bilateral lower extremity lymphedema and bilateral inguinal skin ulcers with lymphorrhea. He had been treated for rectal cancer by low-anterior resection, lymph nodes dissection, colostomy, and subsequent heavy particle radiotherapy for a local recurrence involving pelvic lymph nodes. We planned a reconstruction using a pedicled anterolateral thigh flap that included retrograde collecting lymphatic vessels, with the flap rotated as a propeller flap. The flap successfully survived and clinical symptoms of edema in both lower limbs improved during the short postoperative course. Although the collecting lymphatic vessels within the flap were arranged retrograde to the direction of the anatomical lymphatic flow at the recipient site, linear lymphatic flow consistent with the transferred flap was confirmed by lymphoscintigraphy. This case shows that the lymphatic flow may recanalize after tissue transplantation, even if the collecting lymphatic vessels in the flap are arranged retrograde to the direction of lymphatic flow.