Fasciocutaneous Vascularized Lymph Node Transfer for Head and Neck Lymphedema: A Case Report

Head and neck lymphedema is a common complication of head and neck cancer treatment. Lymphovenous bypass is a promising surgical treatment but may not be an option for all patients after radiotherapy due to the obliteration of local lymphatic targets for bypass. We aim to present vascularized lymph node transfer (VLNT) as a solution to this problem. We report the case of a 38-year-old patient with Stage 2 face and neck lymphedema after treatment for T4aN1oral squamous cell carcinoma, who had no targets for lymphovenous bypass. The patient was treated with a 6 by 14 cm fasciocutaneous VLNT based on the left superficial circumflex iliac artery and vein, to the right facial vein and facial artery. The patient was given a low-dose heparin infusion, placed in a head bolster to prevent neck rotation, and discharged with low-dose aspirin. 4.5 months after free flap reconstruction, the patient underwent revision of the flap including indocyanine green lymphatic mapping, thinning with lymph-sparing liposuction, and re-advancement with Z-plasty for contour. At 11 months, the patient experienced a reduction of swelling, improvement of symptoms, and no further need for compression and manual lymphatic drainage. The area of greatest mobility impairment was resurfaced with flap skin, improving subjective tightness. Indocyanine green imaging at 4 months and 11 months revealed linear lymphatics traversing from the facial skin into the flap. Facial dermal thickness on ultrasound decreased from 1.43 to 1.09 mm between 4 and 11 months postoperatively. Fasciocutaneous VLNT has the potential to restore lymphatic drainage, improving swelling and tightness for patients with head and neck lymphedema who do not have lymphatic targets for bypass. Future studies on head and neck lymphedema should routinely employ ultrasound measurement of dermal thickness as an objective measure.