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Table 1. Advantages and disadvantages of various types of vascularised lymph node transfers
Vascularised
lymph node flaps Advantages Disadvantages
Groin Can be taken with DIEP Flap during breast Iatrogenic lower limb lymphoedema
reconstruction; well concealed scar; good cosmesis;
commonly used for upper limb lymphoedema
Omentum No iatrogenic lymphoedema; rich source of Laparoscopy/laparotomy needed; poor cosmesis; complications due to
lymphatic tissue; laparotomy; adhesions; hernias; DVT
Submental Less iatrogenic lymphoedema Injury to marginal mandibular branch of facial nerve; vessel is small; few
nodes in the flap
Supraclavicular Less iatrogenic lymphoedema Vessel is small; few nodes; damage to brachial plexus and lymphatic duct
Lateral thoracic Commonly used for lower limb lymphoedema Iatrogenic upper limb lymphoedema; damage to the thoracodorsal nerve
Jejunum No iatrogenic lymphoedema Injury to the viscera, bowel adhesions, internal hernia; bowel ischaemia
DIEP: deep inferior epigastric perforator; DVT: deep vein thrombosis

hidden. If it is difficult to access the scar in the anatomical position, then the VLNTs can be placed just
distal to the point of obstruction. For example, in patients who have had pelvic lymph nodes removed after
a laparotomy, the vascularised lymph nodes would then be placed in the upper thigh medial to the femoral
[1]
artery and the saphenous vein .
Vascularised lymph nodes can also be transplanted distally in the limb. The theory behind placing the
VLNT at non-anatomical sites is that they work like a “lymphatic pump”. The strong arterial pulsations
in the flap provide a strong hydrostatic force in the flap. The flap veins, which have low pressure, act
[26]
like a suction drawing the lymphatic fluid into the capillaries . Due to gravity, the lymphatic collection
is predominantly distal, and placing the VLNTs distally seems to have a “catchment effect”, thereby
improving lymphatic drainage. However, distal placement of the flap can make the flap look bulky and
[27]
non-aesthetic . There are many potential donor lymph nodes for VLNTs, namely the groin, thoracic,
submental, supraclavicular, omental and mesenteric lymph nodes. The advantages and disadvantages of the
different donor options are listed in Table 1.

Breast cancer is the most common cancer among women and post-mastectomy lymphoedema occurs in
9%-41% of women who undergo axillary dissection and 4%-10% of women who undergo sentinel lymph
node biopsy [28-30] . In such cases, the DIEP flap is the most commonly used. This flap not only helps in
lymphoedema, but also helps to reconstruct the missing breasts at the same time. The superficial lymph
node basin of the groin drains the lower abdomen and is the target for lymph node harvest, whereas deeper
lymph nodes close to the femoral vessels drain the thigh and lower extremity. While harvesting the lymph
nodes, it is preferable to harvest the lymph nodes lateral to the femoral vessels, since lymphatic drainage of
[31]
the lower limb is predominantly medial to the femoral vessels and below the inguinal ligament . The DIEP
flap is raised as caudally as possible. The groin lymph nodes lateral to the femoral vessels are preferably
harvested along with the superficial circumflex iliac vessels and are placed in the axilla, and the superficial
circumflex iliac vein is anastomosed to either the thoracodorsal vein, the lateral thoracic vein or the serratus
branch. The pedicle of the DIEP flap is attached either to the thoracodorsal vessels or the internal mammary
vessels. The major concern about this flap is about donor site lymphoedema and can be prevented by
[32]
reverse lymphatic mapping using preoperative lymphoscintigraphy, ICG and methylene blue dye .
The supraclavicular flap based on the transverse cervical vessels can be used as a VLNT. Donor site
lymphoedema is not common in this flap, as evidenced by the fact that the lymph nodes in this area are
[33]
commonly removed during elective neck dissections after cancer . The other benefit of the flap is that it
generally heals well with a good scar. The flap dimensions and size are generally small compared to other
donor sites, and this flap is generally placed distally in the limbs to treat lymphoedema, since the soft tissue
cover around the wrist and ankles is much less. Safe harvesting of the supraclavicular flap would need