Submental Lymph Node Transfer to the Lower Extremity

Lower extremity lymphedema can be from either primary or secondary causes. Regardless, surgical management is largely guided by Cheng’s Lymphedema Grading correlated with the Taiwan Lymphoscintigraphy Staging. Lower extremity lymphedema with Cheng’s Lymphedema Grading of Grades II-IV with total obstruction on lymphoscintigraphy is an indication for vascularized lymph node transfer. Vascularized submental lymph node (VSLN) transfer is a highly efficacious, low complication treatment option with a donor basin rich in lymph nodes with consistent anatomy, suitable pedicle length, and sufficient donor veins and arteries. This clinical case illustrates the work-up, considerations, techniques, operative tips, postoperative management, functional outcomes, and pitfalls of performing a VSLN flap transfer. Work-up involves a clinical history, physical exam, and multimodal imaging approaches including lymphoscintigraphy, indocyanine green (ICG) lymphography, ultrasound Doppler, and computed tomography (CT) or magnetic resonance imaging (MRI). Harvesting the submental lymph node flap requires careful dissection, and the recipient site has an equally challenging dissection of recipient pedicles with the creation of a pocket to inset the flap. Postoperative management relies on confirmation of patent anastomoses with Doppler and clinical signs to detect any potential vascular insufficiency requiring re-exploration. Functional outcomes of VSLN flap transfer are reliably good, with significant limb circumference reduction, decreased cellulitis incidence, and quality of life improvement. Aesthetics are equally satisfactory, with minimal scarring and easily hidden incisions, particularly after skin paddle excision 1 year postoperatively.