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Lymphatic System Transfer (LYST) — SCIP Flap Incorporating Lymph Nodes and Afferent Lymphatic Vessels

LYST (Yoshimatsu / Yamamoto and colleagues) is a next-generation physiologic lymphedema operation that combines the benefits of VLNT (vascularized lymph node transfer) and VLVT (vascularized lymph vessel transfer) by harvesting a SCIP flap that deliberately includes superficial inguinal lymph nodes together with their afferent lymphatic vessels as a single functional unit. The first long-term study (n = 8, mean 39 mo) demonstrated 11.2% improvement in excess volume percentage (p < 0.001) with significant cellulitis reduction (p = 0.025).[1] A subsequent pedicled SCIP-LYST series (n = 6) showed zero complications, mean 15-point LLIS reduction, and 30-unit L-Dex decrease — without microsurgical anastomosis.[2]

For the broader condition see Genital Lymphedema and Giant Penoscrotal Lymphedema. For related SCIP-based atlas pages see 3R / SCIP-LFT (Yamamoto), Complete Functional Lymphatic-System Pedicled Transfer (Abdelfattah), and CHASCIP (Ciudad). For canonical free LN transfer see VLNT; for early-stage microsurgery see LVA; for conservative anchor see Complex Decongestive Therapy.

Definition and Conceptual Framework​

LYST is a conceptual evolution beyond traditional VLNT. The distinction lies in what is transferred:[1][2][3]

ComponentTraditional VLNTVLVTLYST
Lymph nodesYesNoYes
Afferent lymphatic vesselsNo (incidental at best)YesYes (deliberately)
Perinodal fat (VEGF-C–rich)YesNoYes
Skin paddleOptionalOptionalYes (SCIP skin)
MechanismNeolymphangiogenesis from nodesDirect lymphatic bypassImmediate drainage via transferred vessels + neolymphangiogenesis from nodes
Neolymphangiogenesis requirementHigh — new vessels from scratchMinimalReduced — pre-existing vessels bridge the gap

LYST was formalized on the observation that traditional VLNT transfers only nodes within perinodal fat, relying entirely on neolymphangiogenesis to establish new connections between transferred nodes and the recipient tissue — a slow (12+ mo) and incomplete process. By deliberately including the long afferent lymphatic vessels that naturally drain into those nodes, LYST provides pre-formed lymphatic channels that can function immediately, reducing the new vessel growth required for physiological drainage.[1][2]

Biological Rationale — Why Afferent Vessels Matter​

  1. Immediate drainage pathways — transferred afferent vessels offer pre-existing conduits for lymph transport, so functional recovery is potentially earlier than with VLNT alone.[1][2]
  2. Reduced neolymphangiogenesis requirement — transferred vessels already span much of the donor-to-recipient distance; less new vessel growth is required.[1][2]
  3. VEGF-C–driven neolymphangiogenesis (complementary) — transferred nodes and perinodal fat remain VEGF-C–rich. Aschen et al. showed massive recipient lymphatic infiltration and putative donor-recipient connections after LN transfer in a murine model.[4] Maruccia et al. provided human histologic evidence — podoplanin-positive lymphatic vessel density rose from 7.92 ± 1.77 to 11.79 ± 3.38 vessels/mm² at 12 mo (p = 0.0008).[5]
  4. Lymph node pump function and immune restoration — transferred nodes absorb interstitial fluid via afferent lymphatics and channel it into the venous system via high-endothelial venules in close anatomic proximity to newly-formed lymphatic channels; T/B-cell populations and dendritic-cell trafficking are restored, explaining the dramatic cellulitis reduction.[4]
  5. Anti-inflammatory / anti-fibrotic effects — Viitanen et al. showed that LN transfer promotes an anti-inflammatory cytokine profile with raised IL-10 and VEGF-C, suppressing the proinflammatory response seen after LN dissection alone.[6]

Lymphatic Anatomy of the SCIP Region — Anatomic Basis for LYST​

The groin provides the ideal donor site because of its well-characterized lymphatic anatomy.[7][8]

Superficial inguinal lymph-node subgroups (Scaglioni / Suami)​

SubgroupDrainage territoryRole in LYST
Abdominal (superolateral)Lower abdominal wall, lower back, upper gluteal regionTarget nodes for LYST harvest — removal does not compromise lower-extremity lymphatic drainage[8]
Medial thighVentromedial thigh via thick-walled (0.6–1 mm) collectors converging on two nodes inferolateral to the saphenous bulbSentinel nodes of the lower leg — must be preserved[7][8]
Lateral thighLateral thigh via thin-walled (0.3–0.5 mm) collectorsNot routinely harvested[7]

Safety principle: limit the medial extent of dissection to the lateral border of the femoral artery — the dominant LE-draining nodes lie in the lower part of the inguinal triangle, with efferents medial to the common femoral artery.[7][8]

Afferent lymphatic vessel anatomy​

  • Lower abdominal collectors course within subcutaneous tissue alongside the SCIA branches.[7]
  • Located above Scarpa's fascia, immediately below the subdermal venules.
  • Thin-walled and translucent, 0.2–0.8 mm diameter.
  • Drain the lower abdominal wall into the superolateral inguinal nodes.
  • Naturally included within the SCIP flap territory when the flap is harvested with intact perinodal fat.

Surgical Technique — Free SCIP-LYST (Yoshimatsu)​

The original LYST description is a free microsurgical flap transfer for extremity lymphedema.[1]

Preoperative planning​

  • ICG lymphography of the groin to map superficial lymphatics and identify afferent channels draining into the superolateral nodes.
  • Reverse lymphatic mapping (ICG + Patent Blue or technetium-99) to identify and protect LE-draining sentinel nodes.[9][10]
  • Ultrasound mapping of SCIA perforators for flap design.

Flap harvest​

  1. SCIP flap designed over the groin crease, centered on SCIA perforators.
  2. Proximal-to-distal dissection to identify the SCIA origin and its superficial / deep branches.
  3. Flap elevated to include the superolateral inguinal nodes, afferent lymphatic vessels alongside the SCIA, perinodal adipose tissue, and a skin paddle for monitoring / coverage.
  4. Medial thigh sentinel nodes strictly preserved — confirmed by reverse lymphatic mapping.
  5. Flap divided from its SCIA / SCIV pedicle.

Recipient site and microsurgical anastomosis​

  • Flap transferred to the lymphedematous extremity (typically ankle, wrist, or proximal limb).
  • Arterial and venous microanastomoses to recipient vessels.
  • Flap inset with nodes and afferent vessels oriented to facilitate distal-extremity drainage.

Postoperative​

  • Standard free-flap monitoring.
  • CDT continued.

Surgical Technique — Pedicled SCIP-LYST (Xu et al.)​

Xu et al. introduced a pedicled SCIP-LYST that eliminates microsurgical anastomosis.[2]

Key innovation: the SCIP flap remains attached to the SCIA / SCIV pedicle and is rotated into the proximal thigh / groin rather than transferred as a free flap — possible because the SCIA origin from the femoral artery offers sufficient pedicle reach.

Population: 6 patients with lower-extremity lymphedema and concomitant chronic venous disease (CVI) — traditionally challenging because venous hypertension impairs lymphatic function.

Combined approach: 5/6 also received distal LVA in the lower extremity for dual-level physiologic reconstruction:

LevelOperationFunction
ProximalPedicled SCIP-LYSTLymph-node pump + afferent-vessel drainage at the groin
DistalLVA at ankle / calfDirect lymphatic-to-venous bypass

Advantages: no microsurgical anastomosis (no anastomotic thrombosis risk); shorter operative time; 100% flap survival; proximal flap placement positions flap lymphatics efferent to the site of venous obstruction — uniquely beneficial in CVI patients, where distal flap placement (as in traditional free VLNT) would site the transferred nodes within the zone of venous hypertension.[2]

Zone-4 Lymphatic SCIP Flap — Simultaneous Breast + Lymphatic Reconstruction (Yoshimatsu)​

Yoshimatsu et al. described a Zone-4 application during DIEP-flap breast reconstruction: the Zone-4 region of the lower abdominal flap (normally discarded) overlies the SCIP territory. By harvesting a separate lymphatic SCIP flap from Zone 4, the surgeon transfers nodes and afferent vessels to the axilla without any additional donor-site morbidity.[11]

Results (n = 7): all lymphatic SCIP flaps survived; prevention cohort (4 patients) — no lymphedema at mean 37.5 mo; treatment cohort (3 patients) — mean estimated volume decrease 12.6% at mean 29 mo.

Saaristo et al. independently validated the concept — a modified lower-abdominal flap containing nodes and lymphatic vessels around the superficial circumflex pedicle improved lymphatic vessel function in 5/6 patients on postoperative lymphoscintigraphy, with 3/9 no longer requiring physiotherapy / compression.[12]

Perforator-to-Perforator SCIP-LYST (Meroni / Scaglioni)​

Meroni and Scaglioni introduced a perforator-to-perforator (P-to-P) microsurgical SCIP-based LYST: the flap is anastomosed to recipient perforator vessels (rather than major source arteries), which preserves major vessels at both donor and recipient sites and positions nodes more superficially — closer to the superficial lymphatic network where they more effectively absorb interstitial fluid.[13]

Preliminary results in 12 patients: ICG-confirmed perfusion in all cases; applicable to both UE and LE lymphedema.

Lymphatic Flow-Through (LyFT) SCIP Flap (Scaglioni)​

Scaglioni et al. expanded the concept by combining a pedicled SCIP flap with LVA between damaged recipient-site lymphatic vessels and the flap's superficial veins — the "Lymphatic Flow-Through" (LyFT) approach.[14] The dual-purpose construct simultaneously provides:

  1. Soft-tissue coverage of groin / thigh defects.
  2. Immediate lymphatic drainage via the LVA between damaged lymphatics and flap veins.
  3. Long-term neolymphangiogenesis through the lymphatic-rich transferred SCIP tissue.

Particularly relevant for sarcoma resection in the groin / thigh, where extensive soft-tissue excision disrupts lymphatic pathways and creates a high risk of postoperative lymphedema.[15]

Clinical Outcomes — All SCIP-LYST Series​

SeriesApplicationnFollow-upKey outcomes
Yoshimatsu 2025 (Free SCIP-LYST)[1]Lower-extremity LE839 mo11.2% excess-volume improvement (p < 0.001); cellulitis ↓ (p = 0.025)
Xu 2026 (Pedicled SCIP-LYST)[2]LE LE + CVI631 wkLLIS ↓ 15 pts; L-Dex ↓ 30 units; 0% complications
Yoshimatsu 2022 (Zone-4 SCIP + DIEP)[11]BCRL prevention / treatment729–37.5 mo0% LE in prevention cohort; 12.6% volume ↓ in treatment cohort
Meroni / Scaglioni 2024 (P-to-P SCIP-LYST)[13]UE / LE LE12Preliminary100% flap perfusion on ICG; successful transfer in all cases
Abdelfattah 2023 (Pedicled SCIP-LYST, genital)[16]Male genital LE2644.9 moGLS 6.2 → 0.05 (p < 0.001); GBI +41; 100% QOL improvement
Yamamoto 2022 (3R / SCIP-LFT, genital)[3]Male genital elephantiasis722.7 moGLS 6.7 → 0.3; 0% complications; 0% recurrence
Ciudad 2025 (CHASCIP, bilateral SCIP-LYST genital)[17]Penoscrotal LE834 moGLS 6.6 → 0.6; sexual dysfunction 87.5% → 0%; 0% recurrence
Pereira 2021 (SCIP-LV posttraumatic)[18]Posttraumatic extremity LE11≥ 12 mo63% excess-volume reduction; 51.85% QOL improvement; 0% LE in prevention cohort

LYST vs Traditional VLNT — Comparative Analysis​

FeatureTraditional VLNTSCIP-LYST
What is transferredNodes + perinodal fatNodes + afferent vessels + perinodal fat + skin
MechanismNeolymphangiogenesis onlyImmediate drainage via transferred vessels + neolymphangiogenesis
Onset of improvementGradual (12–24 mo)Potentially earlier functional recovery
Pedicled optionRarely possibleYes (pedicled SCIP-LYST eliminates microsurgery)
Donor-site LE risk0–7.7% (groin donor)Zero with reverse lymphatic mapping[9][10]
Volume reduction (extremity)20–45.7% at 24 mo[19][20]11.2% excess-volume improvement at 39 mo (free); LLIS ↓ 15 pts (pedicled)
Cellulitis reduction93–97.9%Significant (p = 0.025)
Compression discontinuation34% at 2 yNot required in genital series; ongoing in extremity series
Flap survival95–100%100% across all series

Seidenstuecker et al. showed that LVA produces rapid improvement within 3 mo, while VLNT shows slower but steady improvement over 12+ mo — narrowing the gap over time.[21] LYST may theoretically combine the early profile of LVA (pre-formed vessels = early drainage) with the sustained profile of VLNT (nodes = ongoing neolymphangiogenesis), although direct head-to-head data are lacking.[1][2][21]

Donor-Site Safety — Reverse Lymphatic Mapping (RLM)​

Iatrogenic donor-site lymphedema is the main historical concern for groin-based LN harvest. Multiple strategies minimize this risk.[9][10][22]

Reverse lymphatic mapping (Dayan)​

Dual-tracer injection distinguishes safe-to-harvest trunk-draining nodes from must-preserve LE-draining nodes.[10]

TracerInjection sitePurpose
Technetium-99 or ICGFoot web spacesIdentify LE sentinel nodes (avoid)
Patent Blue dye or ICGLower abdominal skinIdentify abdominal-draining nodes (harvest)

Pons et al. showed ICG-based RLM provides identical results to technetium-99 isotope scanning — safer and more reproducible — with zero donor-site lymphedema in 39 patients.[9]

Broyles et al. used SPECT/CT reverse lymphatic mapping in 84 patients and found that drainage to ≥ 1 superficial inguinal region was visualized in 38.1% — underscoring the necessity of RLM. With intraoperative gamma-probe guidance, zero patients developed donor LE lymphedema at mean 34.5-mo follow-up.[22]

Anatomic safe zone​

The safe SCIP-LYST harvest zone is the superolateral (abdominal) group of superficial inguinal nodes. Medial dissection should stop at the lateral border of the femoral artery.[7][8]

LYST in Genital Lymphedema​

LYST has been most extensively applied to male genital lymphedema, where the SCIP flap's proximity to the perineum permits pedicled transfer without microsurgery. The three major genital-LYST series demonstrate consistent results:[3][16][17]

SeriesnFollow-upReconstructionHeadline outcome
Abdelfattah2644.9 moSingle unilateral pedicled SCIP-LYST for scrotum + penisGLS 6.2 → 0.05
Yamamoto 3R722.7 moUnilateral pedicled SCIP-LYST (scrotum) + separate SCIP pure-skin flap (penis)0% complications, 0% recurrence, no compression needed
Ciudad CHASCIP834 moBilateral pedicled SCIP-LYST (scrotum) + FTSG (penis)Sexual dysfunction 87.5% → 0%

All three series demonstrate 0% lymphedema recurrence — a dramatic improvement over excisional approaches (10–50% recurrence) — attributable to the functional lymphatic restoration provided by the LYST component.

Emerging Applications and Future Directions​

  1. Prophylactic LYST after lymphadenectomy — Caretto et al. showed that immediate inguinal reconstruction with an L-SCIP flap after vulvar groin dissection significantly reduced LE lymphedema (479 ± 330 cc³ vs 683 ± 425 cc³ contralateral; p = 0.022). Directly translatable to pelvic lymphadenectomy for prostate, bladder, or penile cancer.[23]
  2. LYST + adjunctive VEGF-C therapy — perinodal VEGF-C dramatically enhances lymphatic vessel regeneration and preserves transferred LN structure preclinically; control-treated nodes regress and are replaced by fibrofatty scar.[24] Tervala et al. confirmed VEGF-C as the most effective growth factor among the VEGF family.[25]
  3. Posttraumatic lymphedema prevention — Pereira et al. demonstrated 63% excess-volume reduction with the SCIP-LV flap in established posttraumatic disease and 100% prevention when used prophylactically after acute trauma with lymphatic damage.[18]
  4. Hyaluronidase-enhanced neolymphangiogenesis — Cheon et al. showed periodic perinodal hyaluronidase injection enhanced lymphangiogenesis around vascularized LN flaps in a rodent model — a potential pharmacologic adjunct.[26]

Limitations of Current Evidence​

  • Small sample sizes — the largest LYST-specific series for extremity disease (Yoshimatsu) is only 8 patients; genital series are larger but address a different anatomic compartment.[1]
  • No RCTs comparing LYST to traditional VLNT — the theoretical early-recovery advantage has not been directly demonstrated head-to-head.[1][2]
  • Heterogeneous outcome measures (excess-volume %, CRR, L-Dex, LLIS, GLS, GBI) complicate cross-study comparison.
  • Variable follow-up (31 wk to 44.9 mo).[2][16]
  • Most series rely on clinical outcomes rather than objective postoperative lymphatic-transport imaging.[1]
  • Requires expertise in SCIP flap anatomy, ICG lymphography, reverse lymphatic mapping, and — for free LYST — supermicrosurgical technique.[1]

Key Takeaways​

  1. LYST is the conceptual evolution of VLNT — deliberately including afferent lymphatic vessels with their draining nodes transfers a complete functional lymphatic unit rather than isolated nodes.[1][2]
  2. The SCIP flap is the ideal vehicle because the groin contains superficial inguinal nodes with well-characterized afferents that can be reliably harvested within the SCIP territory.[7][8]
  3. LYST can be performed as a free flap (microsurgical) for extremity LE or as a pedicled flap (no microsurgery) for genital LE and proximal LE disease.[1][2]
  4. Pedicled SCIP-LYST is particularly advantageous when CVI coexists — proximal flap placement keeps lymphatics efferent to the site of venous obstruction.[2]
  5. The Zone-4 lymphatic SCIP flap enables simultaneous breast reconstruction and BCRL treatment / prevention with no additional donor-site morbidity.[11]
  6. Reverse lymphatic mapping (ICG or technetium-99) is essential — achieving zero donor-site lymphedema across all series using this technique.[9][22]
  7. Biological mechanisms include immediate drainage via transferred vessels, VEGF-C–driven neolymphangiogenesis, LN pump function via HEVs, and immune restoration with anti-inflammatory / anti-fibrotic cytokine profiles.[4][5][6]
  8. In genital lymphedema, SCIP-LYST has achieved 0% recurrence across all three major series (Yamamoto, Abdelfattah, Ciudad) with near-zero GLS scores and 100% QOL improvement.[3][16][17]

References​

1. Yoshimatsu H, Cho MJ, Karakawa R, et al. The role of lymphatic system transfer (LYST) for treatment of lymphedema: a long-term outcome study of SCIP flap incorporating the lymph nodes and the afferent lymphatic vessels. J Plast Reconstr Aesthet Surg. 2025;101:15–22. doi:10.1016/j.bjps.2024.11.052

2. Xu KY, Finkelstein ER, Wu S, Tadisina K, Mella-Catinchi J. Lymphatic system transfer (LYST) with pedicled SCIP for patients with lymphedema and concomitant chronic venous disease. Plast Reconstr Surg. 2026. doi:10.1097/PRS.0000000000012927

3. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection. J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011

4. Aschen SZ, Farias-Eisner G, Cuzzone DA, et al. Lymph node transplantation results in spontaneous lymphatic reconnection and restoration of lymphatic flow. Plast Reconstr Surg. 2014;133(2):301–310. doi:10.1097/01.prs.0000436840.69752.7e

5. Maruccia M, Giudice G, Ciudad P, et al. Lymph node transfer and neolymphangiogenesis: from theory to evidence. Plast Reconstr Surg. 2023;152(5):904e–912e. doi:10.1097/PRS.0000000000010434

6. Viitanen TP, Visuri MT, Sulo E, Saarikko AM, Hartiala P. Anti-inflammatory effects of flap and lymph node transfer. J Surg Res. 2015;199(2):718–725. doi:10.1016/j.jss.2015.04.041

7. Tourani SS, Taylor GI, Ashton MW. Anatomy of the superficial lymphatics of the abdominal wall and the upper thigh and its implications in lymphatic microsurgery. J Plast Reconstr Aesthet Surg. 2013;66(10):1390–1395. doi:10.1016/j.bjps.2013.05.030

8. Scaglioni MF, Suami H. Lymphatic anatomy of the inguinal region in aid of vascularized lymph node flap harvesting. J Plast Reconstr Aesthet Surg. 2015;68(3):419–427. doi:10.1016/j.bjps.2014.10.047

9. Pons G, Abdelfattah U, Sarria J, Duch J, Masia J. Reverse lymph node mapping using indocyanine green lymphography: a step forward in minimizing donor-site morbidity in vascularized lymph node transfer. Plast Reconstr Surg. 2021;147(2):207e–212e. doi:10.1097/PRS.0000000000007585

10. Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135(1):277–285. doi:10.1097/PRS.0000000000000822

11. Yoshimatsu H, Karakawa R, Fuse Y, Yano T. Simultaneous lymphatic superficial circumflex iliac artery perforator flap transfer from the Zone 4 region in autologous breast reconstruction using the deep inferior epigastric artery perforator flap: a proof-of-concept study. J Clin Med. 2022;11(3):534. doi:10.3390/jcm11030534

12. Saaristo AM, Niemi TS, Viitanen TP, et al. Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients. Ann Surg. 2012;255(3):468–473. doi:10.1097/SLA.0b013e3182426757

13. Meroni M, Scaglioni MF. Perforator-to-perforator SCIP-based vascularized lymphnode transfer to reduce morbidity and increase efficacy in lymphedema surgery: preliminary results with 12 cases. Microsurgery. 2024;44(7):e31249. doi:10.1002/micr.31249

14. Scaglioni MF, Meroni M, Fritsche E. Pedicled superficial circumflex iliac artery perforator flap combined with lymphovenous anastomosis between the recipient site lymphatic vessels and flap superficial veins for reconstruction of groin/thigh tissue defect and creation of lymph flow-through to reduce lymphatic complications: a report of preliminary results. Microsurgery. 2023;43(1):44–50. doi:10.1002/micr.30840

15. Poskevicius A, Meroni M, Fuchs B, Scaglioni MF. Combined perforator flaps and lymphatic procedures in reconstructions after sarcoma resection. Microsurgery. 2024;44(1):e31119. doi:10.1002/micr.31119

16. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of advanced male genital lymphedema with a complete functional lymphatic system pedicled transfer. Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006

17. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. Surgical management of genital lymphedema using the combined Charles' procedure and lymphatic superficial circumflex iliac artery perforator flap transfer (CHASCIP). Microsurgery. 2025;45(5):e70075. doi:10.1002/micr.70075

18. Pereira N, Cambara Á, Kufeke M, Roa R. Prevention and treatment of posttraumatic lymphedema by soft tissue reconstruction with lymphatic vessels free flap: an observational study. Ann Plast Surg. 2021;86(4):434–439. doi:10.1097/SAP.0000000000002525

19. Brown S, Mehrara BJ, Coriddi M, et al. A prospective study on the safety and efficacy of vascularized lymph node transplant. Ann Surg. 2022;276(4):635–653. doi:10.1097/SLA.0000000000005591

20. Schaverien MV, Asaad M, Selber JC, et al. Outcomes of vascularized lymph node transplantation for treatment of lymphedema. J Am Coll Surg. 2021;232(6):982–994. doi:10.1016/j.jamcollsurg.2021.03.002

21. Seidenstuecker K, Müller VA, Halbeisen FS, et al. Long-term comparative effectiveness of microsurgical treatment options for lower limb lymphedema: lymphovenous anastomosis vs. vascularized lymph node transfer. J Plast Reconstr Aesthet Surg. 2026;117:26–32. doi:10.1016/j.bjps.2026.03.048

22. Broyles JM, Smith JM, Wong FC, et al. Single-photon emission computed tomographic reverse lymphatic mapping for groin vascularized lymph node transplant planning. Plast Reconstr Surg. 2022;150(4):869e–879e. doi:10.1097/PRS.0000000000009557

23. Caretto AA, Stefanizzi G, Fragomeni SM, et al. Lymphatic function of the lower limb after groin dissection for vulvar cancer and reconstruction with lymphatic SCIP flap. Cancers. 2022;14(4):1076. doi:10.3390/cancers14041076

24. Honkonen KM, Visuri MT, Tervala TV, et al. Lymph node transfer and perinodal lymphatic growth factor treatment for lymphedema. Ann Surg. 2013;257(5):961–967. doi:10.1097/SLA.0b013e31826ed043

25. Tervala TV, Hartiala P, Tammela T, et al. Growth factor therapy and lymph node graft for lymphedema. J Surg Res. 2015;196(1):200–207. doi:10.1016/j.jss.2015.02.031

26. Cheon H, Chen L, Kim SA, et al. Improved lymphangiogenesis around vascularized lymph node flaps by periodic injection of hyaluronidase in a rodent model. Sci Rep. 2024;14(1):24430. doi:10.1038/s41598-024-74414-4