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Effects of Tissue Flap on Expression of Vascular Endothelial Growth Factor-C (VEGF-C) as a Marker of Improved Inguinal Lymphatic Circulation on Dissected Mice


Background: Radical surgery in cancer patients might result in complications like lymphedema. Tissue transfer procedure and lymphatic reconstruction could be done to manage lymphedema. Few biomarker expressions were identified to be associated with lymphangiogenesis and improved lymphatic system function after dissection. This study aims to evaluate the development of new lymphatic vessels by adding flap tissue after lymphatic dissection, assessed by VEGF-C expression, macrophage infiltration, and fibrotic tissue development.

Methods: This is a non-randomized clinical trial at Animal House Skill Laboratory, Faculty of Medicine, Universitas Indonesia, conducted from January to March 2018. Sprague clawley male mice were aged 8-12 weeks were used and divided into control and trial groups. Each mouse underwent inguinal dissection and was randomized to receive additional flap tissue procedures and then evaluated two months after. Methylene blue dye was used to assess the lymphatic flow. Histopathology and immunohistochemistry examination was used to assess the development of fibrotic tissue. Data analysis was done by using SPSS version 20.0 for Windows.

Results: 18 mice were included in the analysis and divided into two groups. Eight out of 9 mice (88.9%) in the trial group, which received flap tissue, showed lymphatic flow from the visualization of methylene blue, compared to two mice (22.2%) from the control group (p=0.15) two months after surgery. Histopathology examination showed wider fibrotic tissue of the lymphatic system from the trial group (p=0.05). Immunohistochemistry analysis also showed higher VEGF-C (p=0.01) and CD68 expression in the trial group (p=0.15).

Conclusion: The addition of flap tissue might improve lymphatic flow, proven by increased lymphatic circulation and VEGF-C expression.


  1. WHO IARC. Breast Cancer: Estimated Incidence, Mortality, and Prevalence Worldwide in 2012. 2012. [Accessed on 10th August 2022] [Available from:]
  2. Departemen Kesehatan Republik Indonesia. Profil Kesehatan Indonesia. Jakarta. 2007. Cited 10th August 2022. Available from:
  3. World Health Organization. WHO-Regional Office for the Eastern Mediterranean. Treatment policy. In: Guidelines for Management of Breast Cancer. EMRO Technical Publications Egypt. 2006 [Accessed on 10th August 2022] [Available from:].
  4. Zurrida S, Bassi F, Arnone P, Martella S, Del Castillo A, Ribeiro Martini R, et al. The Changing Face of Mastectomy (from Mutilation to Aid to Breast Reconstruction). Int J Surg Oncol. 2011;2011:980158.
  5. Clark B, Sitzia J, Harlow W. Incidence and risk of arm oedema following treatment for breast cancer: a three-year follow-up study. QJM. 2005;98(5):343–348.
  6. Lawenda BD, Mondry TE, Johnstone PAS. Lymphedema: a primer on the identification and management of a chronic condition in oncologic treatment. CA Cancer J Clin. 2009;59(1):8–24.
  7. Hayes SC, Janda M, Cornish B, Battistutta D, Newman B. lymphedema after breast cancer: incidence, risk factors, and effect on upper body function. J Clin Oncol. 2008;26(21):3536–3542.
  8. Cheifetz O, Haley L. Management of secondary lymphedema related to breast cancer. Can Fam Physician. 2010;56(12):1277-1284.
  9. Brennan MJ, DePompolo RW, Garden FH. Focused review: postmastectomy lymphedema. Arch Phys Med Rehabil. 1996;77(3 Suppl):S74-S80.
  10. Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of current surgical treatments for lymphedema. Ann Surg Oncol. 2014;21(4):1195-1201.
  11. Yan A, Avraham T, Zampell JC, Aschen SZ, Mehrara BJ. Mechanisms of Lymphatic Regeneration after Tissue Transfer. PLOS ONE. 2011;6(2):e17201.
  12. Viitanen TP, Visuri MT, Hartiala P, Mäki, MT, Seppänen MP, Suominen EA, et al. Lymphatic vessel function and lymphatic growth factor secretion after microvascular lymph node transfer in lymphedema patients. Plast Reconstr Surg Glob Open. 2013;1(2):1-9.
  13. Krebs R, Jeltsch M. The Lymphangiogenic Growth Factors VEGF-C and VEGF-D, Part 1: Fundamentals and Embryonic Development. Lymphol Forsch Prax. 2013;17(1):30–37.
  14. Ghanta S, Cuzzone DA, Torrisi JS, Albano NJ, Joseph WJ, Savetsky IL, et al. Regulation of inflammation and fibrosis by macrophages in lymphedema. Am J Physiol Heart Circ Physiol. 2015;308(9):H1065–H1077.
  15. Kurniawan F. Pengaruh Penambahan Flap Jaringan Dalam Memperbaiki Struktur Limfatik Inguinal Tikus Yang Dilakukan Diseksi Inguinal. Fakultas Kedokteran Unviersitas Indonesia. 2017.
  16. Doscher ME, Schreiber JE, Weichman KE, Garfein ES. Update on Post-mastectomy Lymphedema Management. Breast J. 2016;22(5):553–560.
  17. Yasa KP, Ningrum NF, Samsarga GW, Hamid ARRH. Staged modified Charles procedure on stage III lymphedema of lower limb: safe and effective: a case report. Bali Medical Journal. 2021;10(2):807–810.
  18. Fowler RT, Walmsley TA. Some pitfalls in the quality control of alkaline phosphatase activity. Clin Chim Acta. 1978;87(1):159–163.
  19. Klopfleisch R. Multiparametric and semi-quantitative scoring systems for the evaluation of mouse model histopathology - a systematic review. BMC Vet Res. 2013;9(1):1–15.
  20. Kinashi H, Ito Y, Mizuno M, Suzuki Y, Terabayashi T, Nagura F, et al. TGF-β1 promotes lymphangiogenesis during peritoneal fibrosis. J Am Soc Nephrol. 2013;24(10):1627–1642.
  21. Prabawa IPY, Lestari AAW, Muliarta IM, Mardhika PE, Pertiwi GAR, Bhargah A, et al. The Stromal Cell-derived Factor-1/CXCL12 3’A-gene Polymorphism is Related to the Increased Risk of Coronary Artery Disease: A Systematic Review and Meta-analysis. Open Access Maced J Med Sci. 2020;8(F):197-202.

How to Cite

Panigoro, S. S., Kurniawan, D., Dien, A., I Gusti Ngurah Gunawan Wibisana, & Devina Adella Halim. (2023). Effects of Tissue Flap on Expression of Vascular Endothelial Growth Factor-C (VEGF-C) as a Marker of Improved Inguinal Lymphatic Circulation on Dissected Mice. Bali Medical Journal, 12(1), 595–599.




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Sonar Soni Panigoro
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Doni Kurniawan
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Alban Dien
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I Gusti Ngurah Gunawan Wibisana
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Devina Adella Halim
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