Journal of Surgical Oncology 2017;115:48–53 Platysma-Sparing Vascularized Submental Lymph Node Flap Transfer for Extremity Lymphedema 1 1 1,2 IGOR POCCIA, MD, CHIA-YU LIN, MSc, AND MING-HUEI CHENG, MD, MBA * 1Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan 2Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan Background and Objectives: Due to its consistent vascular and lymphatic anatomy, the vascularized submental lymph node flap is a reliable option for lymphedema treatment. Despite these advantages, flap harvest requires resection of platysma, which may cause a marginal mandibular nerve pseudo-paralysis. The aim of this study was to investigate the donor site morbidity of an innovative platysma-sparing vascularized submental lymph node flap transfer for treating extremity lymphedema. Methods: Ten patients undergoing platysma sparing submental lymph-node flap harvest were prospectively enrolled in the study and compared with a control group of 10 patients who underwent standard submental lymph-node flap harvest. Photogrammetry analysis was used to assess donor site morbidity with regards to marginal mandibular nerve pseudo-paralysis. Results: All flaps survived. No necrosis of the skin paddle was observed in both groups. There were no marginal mandibular nerve palsies in both group. There were no cases of marginal mandibular nerve pseudo-paralysis in the platysma sparing group. Conclusions: The platysma sparing submental flap, while offering comparable functional improvement for extremity lymphedema, has the advantages of maximizing nerve and muscular preservation, significantly reducing donor site morbidity. J. Surg. Oncol. 2017;115:48–53. ß 2017 Wiley Periodicals, Inc. KEY WORDS: platysma sparing submental lymph-node flap; vascularized lymph-node transfer; donor site morbidity INTRODUCTION elevation to include perforating branches from the submental artery and level I lymph nodes. As reported by previous authors, platysma Lymphedema is a chronic and progressive condition that can resection may affect lower lip position during mouth motion [11,12]. severely affects a patient’s quality of life, which is a multidimensional This condition, known as “marginal mandibular nerve pseudo- formula that comprises emotional, functional, social/family, and paralysis,” is caused by a lack of platysma depressive action on physical domains [1]. elevator muscles, giving an asymmetric smile and an elevation of the Recent microsurgical advances in the treatment of lymphedema lower lip [13,14]. promise encouraging results, and vascularized lymph-node transfer is The aim of this study was to describe and investigate the efficacy of becoming quite popular in improving the defective limb drainage [2–6]. an innovative platysma-sparing vascularized submental lymph-node To date, many international groups are studying lymphedema, but flap in preventing the marginal mandibular nerve pseudo-paralysis. standard treatment guidelines remain debatable. Patient selection criteria, timing and type of surgery, donor and recipient sites, and post- operative care are only small parts of the puzzle to be elucidated [7]. PATIENTS AND METHODS A recent meta-analysis investigated the efficacy of vascularized After institutional board approval, 10 consecutive patients lymph-node flap and lympho-venous anastomosis for the treatment of undergoing platysma sparing submental lymph-node flap harvest for lymphedema [8]. It assessed primary outcomes in terms of extremity lymphedema were prospectively enrolled in the study (Group circumference reduction and secondary outcomes in terms of the need for compression garments in the post-operative period. Even though the authors found comparable primary outcomes in both groups, Commercial Asssociations and Financial Disclosures: No funding was when considering secondary outcomes the patients in the vascularized received for this work. lymph node-flap group appeared to fare much better, with a greater Conflicts of interest: The authors do not have any financial interest or likelihood of discontinuing compressive garments in the distal recipient commercial association with subject matter and/or products mentioned in site transfers [8]. the manuscript. Among different options, the vascularized submental lymph-node Level of Evidence: IV (Therapeutic Studies). (VSLN) flap was reported by the senior author for the treatment of lower *Correspondence to: Ming-Huei Cheng, MD, MBA, FACS, Division of extremity lymphedema, and proved to be a reliable and effective lymph Reconstructive Microsurgery, Department of Plastic and Reconstructive node flap [2]. When compared to more traditional approaches such as Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung groin or axillary flaps which may induce iatrogenic lymphedema of the University, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan. Fax: þ886-3- donor limb [9–10], the VSLN flap has the benefit of being a safer option. 3972681. E-mail: [email protected]; [email protected] Despite the submental scar is inconspicuous, the anatomy is consistent Received 13 June 2016; Accepted 15 June 2016 and the flap is less bulky when compared to traditional groin lymph DOI 10.1002/jso.24350 fl fl node aps, ap harvest has the potential for injury of the marginal Published online 6 January 2017 in Wiley Online Library mandibular nerve. Furthermore, flap harvest requires platysma (wileyonlinelibrary.com). ß 2017 Wiley Periodicals, Inc. Platysma Sparing Submental Lymph-Node Flap 49 regarding number of lymph nodes, arterial course and diameter, differences between left and right side. Surgical Technique: Platysma-Sparing Vascularized Submental Lymph Node Flap Harvest Patient positioning. The patient is placed in the supine position with the head hyperextended and slightly laterally flexed on the contralateral side of flap harvest. Pertinent landmarks on the face, which are useful during dissection, are left exposed throughout the procedure. The corner of the mouth and the lower lip helps to visualize the course of the facial nerve and to see whether the lip moves when the nerve is stimulated. Flap design. Preoperative Doppler sonography with an 8 MHz probe provides the location of the submental artery with its cutaneous perforators. An elliptical skin paddle measuring in mean 9 Â 2.5 cm is Fig. 1. Intraoperative flap design and head positioning. An elliptical drawn 1 cm below and parallel to the lower mandibular border, from skin paddle is drawn 1 cm below and parallel to the lower mandibular the angle to the symphysis. A vertical line, 2.5 cm lateral to the oral border. A vertical line, 2.5 cm lateral to the oral commissure, is commissure, is projected on the flap indicating the medial part of projected on the flap indicating the medial part of platysma spared. platysma spared. (Fig. 1). Great care is taken to maintain at least one cutaneous perforator in the lateral portion of the flap. Marginal mandibular nerve preservation. The skin incision starts at the upper margin and descends deep into the platysma only in A) and compared with a control group of 10 patients who underwent the posterior portion of the flap. With the aid of a surgical microscope or standard submental lymph-node flap harvest (Group B). Senior author high magnification loupes, the marginal mandibular nerve is identified MHC treated all patients. underneath the platysma and above the facial artery, usually Patients with a previous history of neck or facial surgery or perpendicular to it. All its branches are identified and confirmed with botulinum injections, with a facial paralysis, and those without full a nerve stimulator. Sharp dissection or the use of electro-cautery, which dentition were excluded from the study. risk nerve damage, are not recommended. Once the marginal Demographic data were analyzed for descriptive analysis. mandibular nerve has been dissected and protected along its course, Each patient inner inter-canthal distance was measured with a the facial artery is ligated distally and dissection continues more vernier caliper and then used for close range photogrammetry. expeditiously. Photogrammetry analysis was performed using Sketch Up Make Platysma-sparing approach. The inferior border of the flap is version 16.1.1451 (2016 Trimble Navigation Limited, Sunnyvale, CA). incised in the same fashion as the upper margin; in the anterior Patients were asked to smile with teeth showing. On frontal view the portion the incision ends in the subcutaneous plane, while, in the pre-operative and post-operative distance between the base of the posterior area it descends deep into the platysma (Video S1). The columella and the position of the lower vermilion at the level of the first anterior portion of the flap is undermined in a subcutaneous plane three maxillary teeth (central incisor I, lateral incisor II, and cuspid III) until the posterior area is reached. At this point, the platysma is spared was bilaterally measured and recorded. Paired Student-t test was used to and the soft tissues and lymph nodes of the anterior portion are prove difference of means in the distance between the operated and the dissected in a pull-through fashion and kept in the flap. Placing skin non-operated sides. hooks and a retractor to elevate the platysma allows a precise and Post-operative analyses were carried out at 12 months follow-up. complete dissection of the soft tissues deep to the medial portion