Microsurgical Procedures: Vascularized Lymph Node Transfer from the Submental Region

The indications for submental vascularized lymph node flap transfer include Cheng’s Lymphedema Grades 2-4, total obstruction of the lymphatic system in Taiwan Lymphoscintigraphy Staging (TLS) T4-T6, partial obstruction of TLS P1-P3, without patent lymphatic vessels, repeated episodes of cellulitis, and failure to complete decongestive physical therapy. The contraindications are local tumor recurrence and distant metastasis. Preoperative Doppler ultrasound and magnetic resonance imaging are helpful for evaluating the number of sizable lymph nodes and the course of the facial artery. The upper margin of the flap is designed at the lower border of the mandible to result in an inconspicuous scar. One to three marginal mandibular nerves, usually peduncular to the facial vessels, should be carefully preserved with a nerve stimulator under a microscope. Most submental lymph nodes (on average, three sizable lymph nodes >5mm in diameter), around the submandibular gland and facial vessels can be delicately harvested. A width of 5cm from the midline of the medial platysma muscle should be preserved in order to avoid marginal mandibular nerve pseudoparalysis. The submental artery is retrogradely dissected from medial to lateral, and the capsule of the submandibular gland should be harvested with the flap. The vascularized submental lymph node flap has consistent anatomy of greater number of sizable lymph nodes and great diameter of facial vessels. It is a reliable and effective treatment for both upper and lower extremity lymphedema. Delicate surgical dissection of the vascularized submental lymph node flap is the key for the success of treating extremity lymphedema.