Figure 6

Patient with a history of vulvar carcinoma who has undergone superficial lymphadenectomy and resulting lower extremity lymphedema. Incision design for elevation of vascularized lymph node flap based on thoracodorsal vessels and incision design for abdominal incision for inset of flap (black arrows). Green arrows indicate sites of injection of indocyanine green to identify lymph nodes draining the chest for inclusion in the flap. Red arrow indicates the site for inset of the vascularized lymph node flap above the muscular fascia in the region of superficial lymphadenectomy. The patient had undergone technetium injection into the left hand the day prior to surgery in order to identify lymph nodes draining this extremity ('reverse lymphatic mapping’).