Microsurgical Procedures: Vascularized Lymph Node Transfer from the Supraclavicular Region

Introduction

As the popularity and success rates of vascularized lymph node transfers for the treatment of lymphedema increase, the aim has shifted toward overcoming potential donor site morbidity and optimizing the harvest target. Most reports of vascularized lymph node transfer have been for the treatment of lymphedema of the upper extremity, using superficial groin lymph nodes. However, this harbors the risk of injury to the deeper lymphatics at the donor site, resulting in secondary lower limb lymphedema. For treatment of lower extremity lymphedema, potential donor sites for lymph nodes are less straightforward. Utilized nodes primarily include the axillary and submental regions; both have significant potential drawbacks, with potential lymphedema of the upper extremity from axillary nodal harvest, and the unsightly donor scar in the submental position, with the risk of marginal mandibular nerve injury during harvest of the proximate nodes.

To date, there is a relative paucity of literature regarding donor site morbidity. Viitanen et al. performed lower limb lymphoscintigraphy on 10 lymphedema patients who had undergone lymphatic transfer from the groin. While none of the patients had donor-site lower limb adverse symptomatology, the lymphoscintigraphy of the majority of patients showed a slightly slower lymphatic flow in the donor limb compared with the nonoperated limb. A semiquantitative evaluation of lymphatic drainage using a numerical transport index revealed that 2 of 10 patients had abnormal lymphatic function in their donor lower limb. Vignes et al. further highlighted the potential risks of lymph node transfer from inguinal and axillary donor sites. In a study retrospectively examining 26 cases, 38% had significant donor-site morbidity, including secondary limb lymphedema, lymphocele, and chronic donor site pain. These findings warrant seeking a less morbid donor lymphatic basin.

Recent anatomical elucidations of the well-described supraclavicular flap have brought us to explore this region as a source for vascularized lymph nodes. The abundance of lymph nodes in this location, positioned off of the main drainage pathways of the upper extremity, the redundancy of alternative drainage routes from the head and neck, coupled with favorable scar healing in the area, makes the supraclavicular source advantageous and widely applicable.

Concepts