Donor site lymphedema after facial reconstruction with free flaps: assessment and pathogenesis

Purpose of a study: to analyze lymphatic complications in the donor site following the harvest of free flaps for facial reconstruction.

Special attention is given to the comparative evaluation of lymphedema severity after radial forearm, anterolateral thigh, and fibular flap harvesting. Based on anatomical analysis and clinical observations we highlight the extent of lymphatic system disruption associated with each flap type. The article outlines modern preventive strategies, including lymphographic mapping, preservation of lymph axiality, and the LIFT technique. Emphasis is placed on the importance of a multidisciplinary and anatomically conscious approach to flap selection, aimed at minimizing lymphatic trauma and supporting spontaneous lymphatic regeneration.

1. Ahmad F.I., Means C., Labby A.B., Troob S.H., Gonzalez J.D., Kim M.M., Li R.J., Wax M.K. Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction. Head Neck . 2017 Sep;39(9):1888-1893. doi: 10.1002/hed.24863

2. van Zanten M.C., Mistry R.M., Suami H., Campbell-Lloyd A., Finkemeyer J.P., Piller N.B., Caplash Y. The Lymphatic Response to Injury with Soft-Tissue Reconstruction in High-Energy Open Tibial Fractures of the Lower Extremity. Plast Reconstr Surg. 2017 Feb;139(2):483-491. doi: 10.1097/PRS.0000000000003024

3. Ivashkov V.Yu., Denisenko A.S., Ushakov A.A. Lymphangiosarcoma. Sarkomy kostey, myagkikh tkaney i opukholi kozhi Bone and Soft Tissue Sarcomas, Tumors of the Skin . 2022;14(2):22-7. (In Russ.). doi: 10.17650/27823687-2022-14-2-22-27

4. Razavi M.S., Lei P.J., Amoozgar Z., Leartprapun N., Nadkarni S.K., Baish J.W., Padera T.P., Munn L.L. Regeneration of collecting lymphatic vessels following injury. Res Sq [Preprint]. 2023 Jul 3:rs.3.rs-3025656. doi: 10.21203/rs.3.rs-3025656/v1

5. Ivashkov V.Yu., Denisenko A.S., Kolsanov A.V., Verbo E.V. An analysis of the postoperative period in patients with facial defects after reconstructive procedures using a three-stage algorithm and the “Autoplan” software. Voprosy rekonstruktivnoy i plasticheskoy khirurgii Issues of Reconstructive and Plastic Surgery. 2025;28(1):21-29. (In Russ.). doi: 10.52581/1814-1471/92/03

6. Sharapo A.S., Ivashkov V.Yu., Mudunov A.M., et al. Outcomes of using free osteomyofascial flaps for one-stage reconstruction of combined post-resection facial defects with an intraoral component. Opukholi golovy i shei Head and Neck Tumors . 2020;10(2):22-29. (In Russ.). doi: 10.17650/2222-1468-2020-10-2-22-29

7. Cho A.M., Lopez J., Teven C.M., Pourtaheri N., Do N.T.K., Jazayeri H.E., Steinbacher D.M., Blackwell K.E., Ozaki W., Yu J.W. Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review. J Craniofac Surg . 2022 Jul-Aug;33(5):1346-1351. doi: 10.1097/SCS.0000000000008511

8. Sedbon T, Azuelos A, Bosc R, D'Andrea F, Pensato R, Maruccia M, Meningaud JP, Hersant B, La Padula S. Spontaneous Lymph Flow Restoration in Free Flaps: A Pilot Study. J Clin Med . 2022 Dec 28;12(1):229. doi: 10.3390/jcm12010229

9. Sakai H., Matsui C., Miyazaki T., Tsukuura R., Yamamoto T. Lymphatic reconstruction with vascularized lymph vessel flap: lymph-interpositional-flap transfer. Plast Aesthet Res . 2023;10:45. doi: 10.20517/2347-9264.2023.18

10. Itkin GP, Itkin MG. Lymphatic system a forgotten area? Vestnik transplantologii i iskusstvennykh organov Russian Journal of Transplantology and Artificial Organs . 2016;18(3):145-157. (In Russ.). doi: 10.15825/1995-11912016-3-145-157

11. Reshetov I.V., Zakirova A.A., Samoilova S.I. Experience of application of binevral ALT-flap for tongue reconstruction. Voprosy rekonstruktivnoy i plasticheskoy khirurgii Issues of Reconstructive and Plastic Surgery . 2022;25(1):65-76. doi 10.52581/1814-1471/80/08

12. Miyazaki T., Kageyama T. Lymph interpositional flap transfer (LIFT) for upper thigh soft tissue and lymphatic reconstruction without lymphovenous anastomosis. J Surg Oncol . 2021 Feb;123(2):698-699. doi: 10.1002/jso.26291

13. Yamamoto T., Yamamoto N., Kageyama T., Sakai H., Fuse Y., Tsukuura R. Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis. J Plast Reconstr Aesthet Surg. 2021 Oct;74(10):2604-2612. doi: 10.1016/j.bjps.2021.03.014

14. Yamamoto T., Yamamoto N., Doi, K., et al. Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns. Plast Reconstr Surg . 2011;128:941947. PMID: 21681123

15. Du X., Liu C. Application of imaging in lymphedema surgical therapies. Gland Surg . 2020;9(2):582-588. doi: 10.21037/gs.2020.03.24

16. State Registration Certificates for Computer Programs: No. 9438784 "Upper Extremity Volume Calculator", No. 23-k-23-9494 “Lower Extremity Volume Calculator”.

17. Ivashkov V.Yu., Denisenko A.S., Kolsanov A.V., Verbo E.V., Nikolaenko A.N. Mandible reconstruction using the Autoplan software. Plastic Surgery and Aesthetic Medicine . 2024;4-2:58-65. (In Russ.). https://doi.org/10.17116/plast.hirurgia202404258

18. Ivashkov V.Yu., Denisenko A.S., Kolsanov A.V., Verbo E.V., Nikolaenko A.N., Legonkikh A.Yu. Maxillary reconstruction using the “Autoplan” software suite. Nauka i innovatsii v meditsine Science & Innovations in Medicine . 2025;10(1):75-80. (In Russ.). doi: 10.35693/SIM643139

19. Ivashkov V.Yu. Individualization of microsurgical reconstructive operations in patients with wound defects of the head of various origins: Dis. Dr. Med. sci. Samara, 2025. 310 p. (In Russ.).