Vascularized Supraclavicular Lymph Node Transfer for Lower Extremity Lymphedema Treatment

Sir:FigureMicrosurgical methods for lymphedema treatment such as vascularized lymph node transfer are gaining popularity. Most reports of vascularized lymph node transfer have been for the treatment of upper extremity lymphedema, for which superficial groin lymph nodes are typically transferred.1–4 For lymphedema involving the lower extremities, the potential donor sites for lymph nodes are limited. The axillary and submental regions have served as donor sites for vascularized lymph nodes to treat lower extremity lymphedema, but both have major disadvantages.5 Harvesting lymph nodes from the axillary region may cause lymphedema of the upper extremity, and harvest from the submental region results in a visible donor-site scar and the potential for injury to the marginal mandibular nerve. In a search for a better source of vascularized lymph nodes for transfer to treat lower limb lymphedema, we have used the free supraclavicular flap with its deep cervical lymph nodes (Fig. 1). The advantages include no risk of secondary lymphedema or nerve damage at the donor site; in addition, the donor site scar is well hidden. To our knowledge, this is the first report of using the supraclavicular flap as a vascularized lymph node transfer for treatment of lymphedema.Fig. 1: Illustration showing the design of the supraclavicular free flap.The flap is designed as an ellipse in a horizontal orientation just above the clavicle, with the posterior border of the sternocleidomastoid muscle as the midpoint. First, the inferior skin incision is made, and the dissection proceeds lateral to medial until the transverse cervical artery and transverse cervical vein are identified. A handheld Doppler device can be used to identify a perforator; its location can be marked on the skin to facilitate postoperative monitoring. It is not always necessary to visually identify the perforator to the overlying skin; the vessel is small and can be injured if excessive dissection occurs. The larger lymph nodes are often visible and also palpable. Indocyanine green fluorescent dye can be used to confirm the vascularity of the lymph nodes. The recipient site is prepared at the dorsal crease of the ankle, where the anterior tibial artery and veins are dissected out. The flap is transferred to the recipient site, the microvascular anastomoses are performed, and the flap is inset. The donor site is closed primarily. The postoperative course includes gentle wrapping with a compression bandage and elevation. The dangling protocol starts on postoperative day 5, and the patient increases ambulation progressively with full weight-bearing as tolerated (Fig. 2).Fig. 2: (Left) Preoperative view. (Right) Three-month postoperative view. There has been a 23 percent reduction in volume differential, and the leg is significantly softer and lighter. Note the supraclavicular free flap at the ankle.We have used vascularized supraclavicular lymph node transfer for treatment of advanced lymphedema affecting the leg. The donor-site scar is well hidden, and there is no risk of secondary lymphedema or nerve damage at the donor site. Our preliminary results have been very encouraging. Ghazi A. Althubaiti, M.D. Melissa A. Crosby, M.D. David W. Chang, M.D. Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas DISCLOSURE The authors have no financial interests or commercial associations to declare in relation to the content of this article.