Dorsal Wrist Placement for Vascularized Submental Lymph Node Transfer Significantly Improves Breast Cancer-Related Lymphedema

Abstract

Background: Vascularized submental lymph node flap transfer to the wrist is an effective treatment for breast cancer-related lymphedema. Dorsal placement was hypothesized to offer superior outcomes due to favorable venous drainage; however, the flap is more visible in this position compared with the volar side and was a cosmetic concern for patients. This study compared the treatment response of breast cancer-related lymphedema with the placement of vascularized submental lymph node flaps at the wrist, between dorsal and volar recipient sites.

Methods: A retrospective longitudinal study examined 15 patients receiving vascularized submental lymph node flaps at the wrist performed by a single surgeon with a mean follow-up of 17 months. Clinical and biometric analyses, including quality of life questionnaires, circumference measurements, and number of infections were conducted.

Results: All patients showed improvements in quality of life, reduced episodes of cellulitis, and reduced limb circumference measurements compared with preoperative data. Dorsal placement (n = 7) delivered significant reductions in limb circumference at all levels after 1 year (P = 0.04) and in overall function domains in the Lymphedema Specific Quality of Life Questionnaires (P = 0.04) compared with volar placement (n = 8). Venous outflow was greater in the dorsal recipient veins (P < 0.0001).

Conclusions: Patients electing to undergo vascularized lymph node transfer to the wrist should be aware that when both options are effective, dorsal placement offers improvement in outcomes despite reduced cosmesis. These results have been incorporated into an evidence-based treatment algorithm that can inform the patient and physician on the decision-making in the breast and plastic surgical spheres.

Fig. 1.

Flap inset surgical technique. A, The submental flap following harvest; blue arrow denotes the vein, red arrow denotes the facial artery, and yellow arrows denote sizable lymph nodes. B, Surgical marking for dorsal inset. C, Dorsal flap inset. D, Surgical marking for volar inset. E, Volar flap inset.

Fig. 2.

Dorsal inset preoperatively and postoperatively. A, Preoperative. B, One year postoperative, following revision of the flap skin paddle. Reduction in circumference was 40% above the elbow and 30% below the elbow.

Fig. 3.

Volar inset preoperatively and postoperatively. A, Preoperative. B, One-year postoperative circumference reduction was 20% above the elbow and 25% below the elbow. C, One year postoperative, volar view, following the excision of the skin paddle.

Fig. 4.

Treatment algorithm for breast cancer–related lymphedema. LVA indicates lymphovenous anastomosis; Tc-99, technetium-99; VLNT, vascularized lymph node transfer.