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Page 2 of 9 Tawaklna et al. Plast Aesthet Res 2023;10:63 https://dx.doi.org/10.20517/2347-9264.2023.40

INTRODUCTION
Lymphedema is a heterogeneous group of conditions characterized by the loss of functional lymphatic
channels leading to progressive limb swelling. It is a disease of significant morbidity leading to recurrent
bouts of cellulitis - which often require inpatient hospitalizations for intravenous antibiotics, wound
formation, activity restriction and aesthetic deformity. Primary lymphedema results from congenital
lymphatic dysfunction and is subdivided by timing of disease onset. Secondary lymphedema is more
common. In relatively lower-income countries, the most common etiology is filarial worm infection. In
higher-income countries, the disease typically results from iatrogenic damage to the lymphatic system from
oncologic surgery and radiation. Upper extremity lymphedema is seen after axillary lymphatic disruption
frequently due to breast cancer care while lower extremity lymphedema commonly follows treatment of
cancers affecting the groin and pelvis .
[1]

Several criteria have been proposed to diagnose lymphedema using a combination of patient history, clinical
exam findings, and a variety of imaging modalities. Currently, the most widely used classification is the ISL
staging system as proposed by the international society of lymphology. Once a patient has been diagnosed
and appropriately staged, they are typically treated with a period of conservative management which
includes regular evaluation and treatment by a lymphatic therapist with special training in complete
decongestive therapy prior to being considered for surgical evaluation. Surgical therapies involve both
physiologic and debulking techniques. Physiologic procedures include lymphovenous anastomosis (LVA)
and vascularized lymph node transfer (VLNT), while debulking procedures include liposuction and direct
excision. Multiple algorithms for surgical management have been proposed to guide the timing and
selection of therapies but none are yet universally accepted. In general, physiologic procedures are believed
to be most successful in earlier stages (ISL I-II) prior to the irreversible deposition of fibrous and fat tissue
[2,3]
seen in advanced disease .

Lymphovenous anastomosis
Lymphovenous anastomosis is a physiologic procedure in which microsurgical techniques are used to
re-establish lymphatic drainage by coapting lymphatic channels to nearby venules. Classically, this
technique is indicated in early stage lymphedema . More recent studies have shown a role in later stage
[4,5]
[6]
lymphedema and even a synergistic effect with lymph node transfer . As such, LVA can be an effective
adjunct to VLNT in addressing the entire extremity. For the sake of this review, we will only discuss sites of
lymph node transfer.

Donor sites of lymph node flaps
Experience with a variety of donor sites of vascularized lymphatic tissue has been reported in the literature
for the treatment of both upper and lower extremity lymphedema. Described flaps include nodes from the
submental, supraclavicular, thoracic, omental, and inguinal nodal basins . Isolated and mixed series of
[1,7]
each of these flaps have been published, reporting varying degrees of success in reducing symptoms and
limb diameter. At this time, there is no clear “best” donor site for vascularized lymphatic tissue, and the
merits of each flap continue to be debated.

The submental lymph node flap, based on the submental artery, includes both submental and
submandibular lymphatic tissue with an overlying skin paddle. Previous anatomic studies suggest that this
flap can be reliably harvested with 3-4 lymph nodes and a pedicle artery diameter and length of 1.3 mm and
[7]
6.4 cm, respectively . Reported disadvantages of this flap include potential damage to the marginal
mandibular nerve during flap elevation .
[7]