Hilar Vessels of the Submandibular and Upper Jugular Neck Lymph Nodes - Cadaver and Clinical Study for Vascularized Lymph Node Transfer to Lower Extremity Lymphedema

Introduction: Vascularized lymph node transfer (VLNT) for lymphedema is an established surgical method of treatment. Vascularized lymph nodes can be harvested from several donor sites i.e., groin, axilla and neck. There is a concern harvesting nodes from the groin and axilla may lead to donor site lymphedema. This risk is greatly reduced harvesting from the neck due to the abundant supply of lymph nodes here. In this cadaver study, we have shown direct perfusion and venous drainage of lymph nodes via hilar vessels based on named pedicles. We also performed VLNT from the neck to the groin in 9 lower extremity lymphedema cases and present the outcome here.

Methodology and Material: 5 fresh cadaver necks (10 sides) were dissected looking at the submandibular and upper jugular neck nodes. We performed VLNT from the neck to the groins of 9 lower extremities in 9 patients with chronic lower extremity lymphedema. The mean patient age was 50 ± 4 years. The average duration of lymphedema symptoms was 72 ± 24 months.

Results: From the cadaver studies, the upper jugular nodes are supplied by a branch of the superior thyroid artery (most commonly the sternocleidomastoid artery) and the submandibular nodes supplied by branch of the facial artery (most commonly the submandibular branch). Hilar venules were found to be draining into larger hilar veins ultimately into the external jugular, internal jugular or anterior jugular veins. There was a mean of 5 lymph nodes ± 2.2 in the upper jugular group and average of 3 ± 1.5 lymph nodes in the submandibular group. Clinically, 8 out of 9 vascularized lymph node flaps survived. There was no donor site morbidity, At 6 months follow-up, the mean reduction of leg circumference was 40 ± 10% above the knee, 52 ± 25% below the knee and 65 ± 21% above the ankle.

Conclusions: When harvesting upper jugular or submandibular nodes, it is essential to take them off the branch of their named pedicles i.e., superior thyroid and facial artery respectively, to supply live nodes to the recipient lymphedematous limb.