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Microsurgical Procedures: Vascularized Lymph Node Transfer from the Submental Region


Key Points

  • The upper margin of the flap is designed at the lower border of the mandible to result in an inconspicuous scar.

  • 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 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.

  • One to three marginal mandibular nerves should be carefully preserved with a nerve stimulator under a microscope.

  • Most submental lymph nodes around the submandibular gland and facial vessels should be delicately harvested.

  • A width of 5 cm of the medial platysma muscle should be preserved in order to avoid marginal mandibular nerve pseudoparalysis.

  • The submental artery should be retrogradely dissected from medial to lateral, and the capsule of the submandibular gland should be harvested with the flap.

Introduction

Increasing options for vascularized lymph node (VLN) donor sites have allowed surgeons to make individualized patient-specific decisions in every case. A variety of donor site options are paramount to decision-making because certain patients may or may not be candidates for flap harvest from specific donor sites. The groin donor site is a popular and common source for VLN transfer. In the setting of lower extremity lymphedema, this option may not always be indicated due to an increased risk of inducing morbidity in the unaffected extremity. The submental VLN flap represents a valuable option for a donor source of VLNs distant from the extremities.

A submental flap has been previously described in the setting of locoregional flap coverage of the head and neck region. This flap, based on the axis of the submental artery, was initially described in 1990 as a reliable cervical flap for a wide range of defects.

Since the initial description of a submental flap, further cadaveric and clinical studies have found this flap to be versatile in the free or pedicled variety. In addition, refined anatomic considerations have allowed versatility in the design of this flap. The recent cadaveric dissection for knowledge of the detailed anatomy of the facial artery and its perforators, as well as the number of sizable submental lymph nodes, has been quite useful in clinical practice. Although many of the advancements implemented for this flap have helped decrease donor site morbidity and improve flap design, special consideration must be given to the anatomic variation of the VLN flap. This chapter will highlight the specific anatomy and surgical technique related to the successful execution of this submental VLN flap.

Concepts

The submental VLN flap, based on the axis of the facial-submental artery, is not similar in design or elevation to the traditional submental flap, in which a skin paddle was designed in the midline below the chin and used for locoregional soft tissue coverage of the head and neck.

Instead, the submental VLN flap skin paddle was designed along the lower margin of the mandible. Initially, a width of 10×5 cm was used to include the anterior belly of the digastric muscle, and this approach has been altered to 6×2.5 cm (close to the mandibular angle) in order to include one to two skin perforators; additionally, a width of 5 cm of the medial part of platysma has been used to avoid the inability to lower the bottom lip, which is a symptom of marginal mandibular pseudoparalysis. Specific technical considerations must be given to the location, preservation, and perfusion of the lymph nodes in the region.

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