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Tawaklna et al. Plast Aesthet Res 2023;10:63 https://dx.doi.org/10.20517/2347-9264.2023.40 Page 3 of 9

The supraclavicular lymph node flap is a thin flap based on the transverse cervical vessels. Its advantages
include a relatively inconspicuous donor site and minimal excess tissue that reduce the need for subsequent
flap thinning. The flap, however, is typically only harvested from the right neck as harvesting from the left
[7]
neck carries the risk of damage to the thoracic duct . Harvest from either neck can result in damage to the
supraclavicular nerve, leading to superior chest wall numbness .
[7]
The thoracic lymph node flap is a larger flap that brings the level 1 axillary node based on either the
thoracodorsal or lateral thoracic arteries. It typically includes more soft tissue bulk than other vascularized
lymph node flaps, which could be advantageous in resurfacing larger defects . However, its use is
[7]
frequently limited due to the risk of causing iatrogenic upper extremity lymphedema . Additionally, there
[8]
are reported concerns regarding the reliability of the vascular pedicle as well as potential injury to the
thoracodorsal nerve during harvest .
[7]
The omental lymph node flap offers potentially the largest amount of lymphatic tissue of all described flaps
in use for VLNT. It includes large lymphatic chains along both the right and left gastroepiploic vessels [9,10] . It
is typically elevated on the right gastroepiploic system but has also been described as a flow-through flap or
being split into two flaps based on the right and left systems, respectively [9,10] . Its advantages include a large
lymphatic basin and minimal risk for donor-site lymphedema. It can be harvested using laparoscopic or
mini-open techniques, resulting in little donor site scarring [11-14] . Its disadvantages include the risks
associated with intra-abdominal surgery and the lack of an available skin paddle [9,10] . Additionally, groups
performing a high volume of this flap have reported concerns for significant venous hypertension and
accordingly recommend anastomosis of the distal gastroepiploic venous stump for additional outflow .
[15]
The groin lymph node flap has been probably the most widely reported donor site for VLNT. The flap can
be variably raised on either the superficial circumflex iliac artery or the medial branch of the common
femoral artery, including up to 6.2 nodes. The flap typically includes a thin overlying skin paddle. Its
reported advantages include a reliably large number of nodes and an inconspicuous donor site scar.
However, it carries a risk of donor-site lymphedema, which limits its utility in the treatment of lower
extremity lymphedema [8,16] .

Reverse lymphatic mapping
Reverse lymphatic mapping is an imaging technology that aims to limit the risk of donor site lymphedema
after harvest of vascularized lymphatic tissue. Using a combination of radioisotopes, a given nodal basin of
interest can be investigated to differentiate nodes that drain an extremity versus those that drain the trunk.
Using this information, flaps can be designed to harvest only those nodes that drain the trunk, thereby
obviating the potential for iatrogenic lymphedema in the donor limb. As it was first described, the technique
required nuclear medicine imaging pre-operatively which carried a significant cost burden. A subsequent
modification using only a combination of indocyanine green and blue dye intra-operatively has been
described which significantly reduces cost and the inconvenience of the original technique. In a series of 39
patients in which the two techniques were compared for design of a vascularized groin lymph node flap, the
lower cost indocyanine green/blue dye technique showed no increase in donor site lymphedema .
[17]
RECIPIENT SITES
There is no consensus on the optimal recipient site for lower extremity VLNT. Successful reduction in limb
circumference, decrease in infection incidence, and/or increase in patient reported quality of life have been
achieved using proximal, mid, and distal lower extremity as recipient sites. A recent landmark systematic
review and meta-analysis concluded that there is grade 1B evidence to support the efficacy of VLNT in