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Beederman et al. Plast Aesthet Res 2022;9:54 https://dx.doi.org/10.20517/2347-9264.2022.64 Page 3 of 7

more variable. Several cadaveric studies have examined the anatomy of the SC lymph node flap in more
detail. The average pedicle length of the transverse cervical artery is between 3-5 cm, with an arterial caliber
of between 1.5-3 mm, depending on the site of harvest [12,13] . Additionally, Gerety et al. examined ten
cadaveric specimens and found 1-8 lymph nodes within the flap (2.6 +/- 1.6 grossly and 3.0 +/- 2.2
microscopically) .
[13]

TECHNIQUE
The supraclavicular lymph nodes are harvested with the patient in a supine position and the head tilted
approximately 45 degrees away from the side of the harvest. This positioning can often allow for
simultaneous harvest of the SC lymph nodes and preparation of the recipient site. Preoperatively, the
anatomical landmarks of the EJV, the SCM, and the clavicle are marked. If the lymph nodes are to be
harvested without a skin paddle, a 5-7 cm longitudinal incision is designed in the patient’s native skin
crease, approximately 2 cm above the superior border of the clavicle within the aforementioned triangle
[Figure 1]. If a skin paddle is to be harvested, the same positioning applies; care should be taken to Doppler
and mark the perforator to the skin paddle, and then design an ellipse with this point in the center.

The operation begins with a skin incision, either along the longitudinal incision (no skin paddle) or along
the superior border of the designed ellipse (skin paddle). The first layer encountered is the platysma, which
is divided sharply. Deep into the platysma, the supraclavicular nerves may be encountered and may need to
be divided to allow for deeper dissection. Dissection proceeds posteriorly. Deep into the platysma, the
omohyoid muscle or tendon is seen and subsequently divided. Once divided, a soft tissue mass consisting of
fat and lymph nodes can be seen posteriorly.

We first begin with the medial dissection of the supraclavicular lymph nodes by identifying a clear plane
along the lateral border of the SCM. As dissection proceeds, the internal jugular vein (IJV) is encountered,
and the mass of soft tissue and lymph nodes is gently dissected off this structure. Dissection proceeds
posteriorly until the anterior scalene muscle is encountered. This serves as the posteriormost border of the
flap dissection. We then gently retract the IJV and identify the TCA arising from the thyrocervical trunk
[Figure 2]. It is important to note that there can be significant variation in terms of the size and location of
the TCA - additional dissection towards its origin and ligation of other branches may be required to obtain
an artery with sufficient caliber and pedicle length. There is often an accompanying vein with the TCA - a
second vein can also be harvested from the EJV for additional venous drainage. In some cases, the vascular
pedicle is identified laterally, and then the flap is raised off the scalene from lateral to medial towards the
origin of the pedicle. Additionally, when the vein is very small, an arterial anastomosis can be done first to
help identify the best choice for venous drainage.

Lateral dissection begins at the previously mentioned lateral border of the triangle, the EJV. Dissection
proceeds posteriorly until the anterior scalene is reached. During this portion of the dissection, the distal
ends of the transverse cervical vessels are encountered and ligated. Additional length of the distal ends of
the TCA and TCV can also be preserved and used for micro anastomosis if needed. During this portion of
the dissection, small lymphatic vessels are often encountered. These are carefully clipped (on the patient
side) to prevent any subsequent lymph leaks. The lymphatic vessels on the flap side are left unclipped
[Figure 3].

At this point, both the medial and lateral dissection of the lymph nodes has been completed, and the
vascular pedicle has been identified. Posterior dissection then proceeds as the lymph node soft tissue mass is
dissected off the anterior scalene muscle. During this step of the procedure, care must be taken to identify