Through an anatomical study by Cheng et al. involving ten groin dissections in five cadaveric studies, vascularized groin lymph node flap can be transferred basing on superficial circumflex iliac artery or a medial branch from the femoral artery [3]. There are two groups of lymph nodes that could be transferred, including the superficial row and the medial column, basing on either the superficial circumflex iliac artery or the medial branch of the femoral artery. In average, a total of 6.2 ± 1.3 lymph nodes could be identified in the groin area with 3.4 ± 0.3 nodes in the superior row and 2.8 ± 1.5 in the medial column. The length and diameter of the arteries were 2.5 cm and 1.5 mm in the superficial iliac artery and the medial branch of the femoral artery.

Before preoperative marking, the selection between the superior row and the medial column of the lymph nodes can be based on preoperative Doppler study as well as the Doppler signal of the artery. However, the medial artery is preferred due to better perfusion from it to the skin flap. The dissection can be started with a lateral incision and the dissection can be made all the way down to the Sartorius fascia. The flap can be elevated once the pedicle has been found. It is not necessary to identify the lymph nodes.

Trying to explore more donor vascularized lymph node flap, Cheng and colleagues did a cadaveric anatomical study to confirm the presentation of lymph nodes inside the flap and applied the vascularized submental lymph node flap for treatment of lower extremity lymphedema after uterine cancer staging with pelvis lymph node dissection [13]. The VSLN flap is nourished by submental artery, which arises from the facial artery. After branching from the facial artery, the submental artery passes through the submandibular gland and runs medially across the mylohyoid muscle. After the mylohyoid muscle, it goes either superficial or deep to the digastric muscle and gives 1–4 skin perforators through the platysma muscle to the overlying skin. From a cadaveric study, an average of 3.3 ± 1.5 lymph nodes can be identified in the flap. Including the facial artery, the pedicle length is as long as 6 cm, which is more than adequate for safe flap transfer and anastomosis.

Before surgery, the facial artery can be palpated along the mandible angle and should be marked. An elliptical skin paddle of about 4 × 9 cm can be designed in the submental area. Incision is first made along the mandible margin. The distal facial artery and vein around the mandible angle should be first explored and marked. The marginal mandibular nerve, which is usually close to the distal facial artery and vein, is then identified and carefully preserved. The flap is then dissected with inclusion of the subcutaneous tissue as much as possible. In order to preserve the skin perforators, the anterior belly of the digastric muscle can be included in the flap. After the submental artery and vein are identified, the flap can be elevated. It is recommended to preserve the soft tissue around the junction of the facial artery and submental artery as much as possible to include the lymph nodes as many as possible.

Transverse cervical artery based lymph node flap was applied for lymphedema surgery by Chang and Chen [12, 15]. Located on the lower neck, transverse cervical artery based lymph node flap has the advantages of being soft, easy to be dissected, thin with better recipient site cosmesis. However, compared to the submental lymph node flap, the donor site scar is relatively more obvious and the width of the flap taken is limited for primary donor site wound closure. In rat model, six lymph nodes could be identified over the transverse cervical artery nourished area. However, there is no large series study using TCA flap for surgical treatment of lymphedema so far.

Lateral thoracic area is a donor site rich in donor arteries and has been used as a flap donor site since 1970s. It contains the skin between the anterior and posterior axillary line. The cutaneous pedicle was from thoracodorsal pedicle or lateral thoracic artery. Due to the anatomical variation, the lateral thoracic flap was not popular. However, in recent years, due to the high interest on lymph nodes, surgeons started exploring more donor sites that could provide vascular lymph nodes for transferring without affecting the donor site, and the lateral thoracic area has been considered a good one because the axillary lymph nodes are actually separated into two groups, draining the upper extremity and thorax. The group of lymph nodes draining the thorax is considered a good donor site for vascular lymph nodes without causing lymphedema on the upper extremity.

According to an anatomical study by Barreiro, the lateral thoracic artery arises from the axillary and takes a straight course deep in the subcutaneous tissue between the anterior axillary line and mid-axillary line. It takes about 2.7 cm from its origin to reach lymph nodes nourished by it. There is usually one vein accompanying the artery, and the average size of the artery and vein is 1.3 mm and 2.6 mm, respectively. The lateral thoracic artery contains 3–7 lymph nodes along its course and a skin flap of about 7 × 14 cm nourished by it.

Preparation of the recipient sites starts with incision of the selected recipient site. Before approaching the recipient vessels, there are usually a lot of fibrotic tissues around and it is recommended to remove part of the fibrotic tissues and create a pocket that is large enough for flap inset. After flap transfer, the lymph node flap will start to suck the lymphatic fluid immediately and soon become swollen. A tight pocket will result in larger tension and compress the vascular pedicle, which further compromises flap perfusion and causes functional loss on the flap.

The recipient artery and vein are selected based on preoperative study. Once the recipient artery and vein are identified, they are commonly found embedded with fibrotic tissue. The fibrotic tissue should be removed as much as possible as these fibrotic bands may limit the flow and result in poor postoperative outcome.