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Page 6 of 13 Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70

thorough knowledge of the local anatomy and the consequent complications that can arise. The transverse
cervical vessels can have a variable course. It can take its origin from either the thyrocervical trunk (80%)
[34]
or directly from the subclavian artery (20%) or rarely from the internal mammary artery . Careful surgical
technique is necessary to avoid damage to the carotid artery, internal jugular vein, phrenic nerve and the
[35]
thoracic duct . The other concern about this flap is that it is thought to have fewer lymph nodes that can
[36]
be transferred .
The submental flap based on the submental artery is a commonly used flap for head and neck
[37]
reconstruction . This flap can be raised as a free flap containing the submental lymph nodes and used
to treat upper and lower limb lymphoedema. Similar to the supraclavicular flap, removal of the lymph
nodes in the neck is inconsequential regarding donor site lymphoedema as evidenced by their routine
harvest during oncological lymph node dissections. A small elliptical skin paddle can also be included.
The upper border of the incision is along the lower border of the mandible and extends from the angle to
the symphysis. Dissection is performed deep to the platysma. The anterior belly of the digastric muscle
can be included to avoid damage to the perforators supplying the flap. Soft tissue around the junction of
the submental and facial vessels is included to provide more lymph nodes in the neck. The main concern
regarding the submental flap is the possible injury to the marginal mandibular nerve that one should be
[38]
wary of while raising the flap . Furthermore, the pedicle can be very short, which may need including the
[39]
facial vessels to make it longer .
The lateral thoracic flap involves the transfer of lymphatics between the anterior and posterior axillary
[40]
folds lateral to the pectoralis minor . The dominant vascular supply to these nodes is from the lateral
thoracic vessels. The artery can be absent in 12.5% of cases, in which case the thoracodorsal vessels provide
[40]
the vascular supply to these nodes . The main advantage of this flap is the inconspicuous scar which is
well hidden in the axillary fold and the longer pedicle length when compared to the other peripheral lymph
node flaps. The main disadvantage of the flap is that lymphoedema can occur in the potential donor site in
the upper limb.

The greater omentum can be harvested as a free flap based on the gastroepiploic vessels to treat
lymphoedema. The omentum has abundant lymph nodes and helps to initiate absorption from the peritoneal
[41]
cavity . Hence, the omentum makes an ideal flap for draining stagnant lymphatic fluid. The large size
of the omentum can be used to cover larger areas and can even be divided into two to treat bilateral
[42]
lymphoedema . Raising the omental flap via a laparotomy can result in abdominal wound infections,
[43]
hernias, prolonged ileus and bowel obstruction . Harvesting the omental flap by laparoscopy obviates the
disadvantages that a laparotomy has by decreasing pain, discomfort, blood loss, wound infections, chest
[44]
infections, prolonged ileus and bowel obstruction and deep vein thrombosis . The major drawback of this
flap is the need for laparoscopy and poor aesthesis associated with the bulk and skin grafting of the flap.

The jejunal mesenteric lymph node flap is also a very good option to avoid donor site lymphoedema
following lymph node transfer. The mesentery in the jejunum is preferred to that in the ileum as it has
more lymph nodes in the flap. The longest loop of the third part of the jejunum is identified and a flap
[45]
based on the second, third or fourth mesenteric branch of the superior mesenteric artery is designed . The
proximal segment has significantly more lymph nodes than the other segments do, and the flap is raised
preferably close to the root of the mesentery. To avoid a risk of internal hernia, only the anterior peritoneum
containing the mesenteric lymph nodes and adjacent branches of the superior mesenteric vessels is raised,
leaving behind the posterior peritoneum intact. Disadvantages of the flap include the risk of injury to the
viscera, bowel adhesions, internal hernia and the need for bowel resection in case of bowel ischaemia.

The outcomes of VLNTs seem very promising according to various reports [45-47] . However, one needs to
take steps to avoid complications. The paramount concern that one has while raising these flaps is not