50-year-old woman with right arm pain and swelling. Past medical history significant for right breast cancer.
What's your differential?
We considered angiosarcoma (given breast cancer and chronic lymphedema), massive localized lymphedema (given history and mass-like appearance, though not the typical appearance), and liposarcma (given fatty component).
The answer surprised us.
This is an omental flap for treatment of chronic refractory lymphedema.
The omomentum is a highly vascularized intra-abdominal structure that is basically a flattened lymph node and provides excellent protection against inflammation and irradiation.
The omentum can be exteriorized and lengthened into a vascular pedicle.
Preoperative lymphoscintigraphy with SPECT/CT scan of the affected regional lymph nodes is typically done prior to surgery. Otherwise, imaging has no role.
You can see a video of omental flap harvest here
https://journals.lww.com/plasreconsurg/Pages/videogallery.aspx?videoId=658&autoPlay=true
References:
Nguyen AT, et al. Laparoscopic Free Omental Lymphatic Flap for the Treatment of Lymphedema. Plastic and Reconstructive Surgery: July 2015 - Volume 136 - Issue 1 - p 114–118
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