Journal of Surgical Oncology
Surgical Anatomy of Vascularized Submental Lymph Node
Flap:
Shared Vascular Contribution of Submental Artery with
Facial Artery and
Topographic Relationship with Anterior Belly of Digastric
Muscle
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Journal: Journal of Surgical Oncology
Manuscript ID Draft
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Wiley - Manuscript type: Research Article
Date Submitted by the
n/a
Author:
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Key Words:
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Complete List of Authors: Piyaman, Parkpoom; Department Anatomy, Faculty of Medicine Siriraj
Hospital, Mahidol University
Patchanee, Krittayot; Department Anatomy, Faculty of Medicine Siriraj
Hospital, Mahidol University
Oonjitti, Thanaphorn; Department of Anatomy, Faculty of Medicine
Siriraj Hospital, Mahidol University
Ratanalekha, Rosarin; Department of Anatomy, Faculty of Medicine
Siriraj Hospital, Mahidol University
Yodrabum, Nutcha; Division of Plastic and Reconstructive Surgery,
Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol
University
Submental lymph node, Submandibular lymph node, Vascularized lymph
node transplantation, Lymphedema
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Surgical Anatomy of Vascularized Submental Lymph Node Flap:
Shared Vascular Contribution of Submental Artery with Facial Artery and
Topographic Relationship with Anterior Belly of Digastric Muscle
Parkpoom Piyaman, MD1, Krittayot Patchanee, MD1, Thanaphorn Oonjitti, MD1, Rosarin
Ratanalekha, MD1, Nutcha Yodrabum MD2*
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Department of Anatomy, Faculty of Medicine Siriraj Hospital, Mahidol University
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Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of
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Medicine Siriraj Hospital, Mahidol University
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* Corresponding author: Nutcha Yodrabum
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Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine
Siriraj Hospital, Mahidol University
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2, Wanglang Road, Bangkok Noi District, Bangkok, Thailand, 10700, 66 2 419 8002
Email: n.yodrabum@gmail.com
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Presented at the 8th World Symposium for Lymphedema Surgery, April 2016, Taipei, Taiwan
Running head: VSLN flap facial artery digastric muscle
Synopsis: Forty vascularized submental lymph node flaps were dissected from 23 cadavers.
Facial artery contributed significantly arterial supply to the lymph nodes in the area.
Keywords: Submental lymph node, submandibular lymph node, perforator, vascularized
lymph node transplantation, Lymphedema, Histology
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Abstract
Background and objectives: Contribution of facial artery in vascularized submental lymph
node (VSLN) flap was neglected and relationship with the anterior belly of digastric muscle
(ABDM) was elusive. This study aimed to elaborate anatomy of the lymph node in aspects of
arterial supply and relationship with ABDM.
Methods: 40 VSLN flaps were harvested from 23 cadavers. The lymph nodes and arterial
supply were studied macroscopically and under microscopy. The nodes were classified by
arterial supplies, location along longitudinal axis and relationship with ABDM.
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Results: VSLN flap had 4.4 ±1.9 lymph nodes by average predominantly located in posterior
three-quarter. Submandibular nodes supplied by facial artery were 1.2 ± 0.9 by average
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dominating in posterior quarter. Half of submental perforators were originated deep to
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ABDM and extended to the nodes in every zones. Lateral to ABDM located the most
surgically accessible submental nodes. Nevertheless, their arterial supply sometimes came
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from the perforators located deep to ABDM. Only 1.2 ±1.1 submental nodes per flap
remained free from ABDM.
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Conclusion: Flap could be reduced to posterior three-quarter of original due to node
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concentration. Facial artery should be harvested to obtain submandibular nodes. ABDM
should be sacrificed due to intimate relationship with arterial supply to submental nodes.
Introduction
Vascularized lymph node transplantation (VLNT) is becoming mainstream surgical treatment
for chronic lymphedema beside lymphovenular anastomosis (LVA). Despite much
complicated procedures, advantage of VLNT over LVA was demonstrated in clinical
outcomes among advanced stage lymphedema [1]. Varieties of donor sites have been
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proposed [2]. The key principle is a direct correlation between the number of transferred
lymph nodes and the improvement on lymphatic function [3]. Focusing on lower extremity
lymphedema, submental flap was advantageous according to higher number of lymph nodes
followed by groin and supraclavicular flap [4].
Vascularized submental lymph node flap is harvested from cervical zone Ia and Ib. The
surgery collects lymph nodes, the submental artery as major donor artery, and venous
tributaries to secure viability of the nodes. Comprehensive anatomical studies were
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conducted on number and distribution of lymph nodes [5, 6, 7]. Although histology remains
gold standard for lymph node identification, the only histological study was conducted in
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small group of 6 specimens from 3 cadavers [7]. Other modalities included visualization
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during dissection [6], ultrasonography [5, 6] and MR imaging [5]. Despite of the difference in
modalities, the studies show similar trend about concentration of lymph nodes in posterior
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part of flap [5, 6] or around submandibular glands [5]. The evidences should have realized a
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smaller flap design that reduced conventional flap area to posterior half. Nevertheless,
surgical dilemmas remain unsolved: firstly, whether or not to include the facial artery in the
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Journal of Surgical Oncology
flap. The inclusion of the artery was previously considered only by intended pedicle length
since the artery had been convenient resource for pedicle extension. Nevertheless, the facial
artery also supplies lymph nodes located in flap area; the submandibular group. Previous
studies focused on identification of submental lymph nodes [6, 7], hence number of
submandibular lymph nodes is still elusive. True number, if appears substantial, may worth
sacrifice of facial artery that benefits in increasing number of the lymph nodes and mobility
of the flap. Secondly, majority of the submental artery run deep to the anterior belly of
digastric muscles [8]. How submental perforators supply lymph nodes located superficially to
the muscles has come to question. According to previous study [9], one may imply that the
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perforators penetrate the muscles to supply the superficial nodes. New insight into
topographic relationship between muscle and arteries should resolve whether or not to
sacrifice digastric muscles for viability of the lymph nodes.
Materials and methods
Forty vascularized submental lymph node flaps were obtained from 23 fresh cadavers. The
cadavers were self-donated by living will to Department of Anatomy, Faculty of Medicine
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Siriraj Hospital, Mahidol University. Based on donation records, cadavers were Thai
nationality, 10 males and 13 females in the age range of 56-76 years. Exclusion criteria were
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1) visible cranial and cervical deformity. 2) medical history of lymphatic diseases involved
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head and neck. 3) visible surgical wound to cervical zone Ia and Ib if the cadavers were
subjected to other medical training or research prior to our study. The procedure was
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approved by Siriraj Institutional Review Board (SiRB) with protocol number
366/2561(Exempt).
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To visualize the vessels, external carotid arteries of both sides were cannulated, irrigated with
0.9% saline solution and injected with red polyacrylamide solution [10]. The solution was
produced in two parts. For part A, forty milliliters of 40% acrylamide gel (19:1) was mixed
with 40 ml of acrylic color (Daler-Rowney, England). For part B, 80 µm of
tetramethylehylenediamine (TEMED) are mixed with 0.8 ml of 10% ammonium persulphate.
Then, part A and B were mixed immediately before injection. The solution is injected 80 ml
per vessel, 160 ml per head. After injection, the specimens were left in 25°c environment for
an hour until the polymerization was completed.
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Dissection of vascularized submental lymph node flap was adapted from previous study [6].
Flap design was elliptical skin paddle where longitudinal axis ran from mental protuberance
(gnathion) to angle of mandible (gonion). Medial curve was demarcated roughly by both
bellies of digastric muscle, while lateral curve by inferior mandibular border. Then, 3
imaginary lines were drawn perpendicularly to the longitudinal axis dividing flap into 4
quarters (Q1 ~ Q4) from anterior to posterior end (gnathion to gonion) (Fig. 1a). The flaps
were approached laterally to include the anterior belly of digastric muscles, entire submental
artery, a segment of facial artery from its origin to mandibular border, and part of
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submandibular gland (Fig. 1b). The superficial lobe of the gland was cut partially. In some
case whereas the gland was not overlapped with other crucial structures it was preserved with
the body.
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We adapted measurements from previous study [6] to produce comparable results.
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Measurements included a) length of inferior mandibular border from gnathion to gonion, b)
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lengths and diameters of the facial and the submental artery and c) mandibular projection
(MP) defined as a location of the structures projected on mandibular border. The projection
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was also represented in percentage of total length of mandibular border. (Fig. 2a).
Additionally, size and distribution of the lymph nodes were recorded then classified by blood
supply, quarter, and zone. For blood supply, the nodes were classified into submandibular
group supplied by facial artery and submental group supplied by submental arteries. For
quarter, the nodes were classified by position along longitudinal axis of the flap into Q1 ~ Q4
(Fig. 1, 2a). For zone, the nodes were classified by relationship with ABDM into medial,
superficial, deep and lateral zones (Fig. 2b).
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Once removed, flaps were hardened in 10% formalin then sliced by 2-mm thickness. The
lymph nodes were recounted under stereo microscopy. The slices of flap were subjected to
serial microscopic section for final structural identification and topography. To achieve
precise relationship, the specimens were carefully oriented from dissection histological
process whereas dermis on each slice was conserved as the superficial demarcation (Fig. 1).
Result
The arteries
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The facial artery was measured 68.6 ±19.9 mm in length from origin to crossing point (Table
I). Along its course, the artery branched off the submental artery at 44.6 ±16.5 mm from the
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origin, which located 77.0 ±9.0% of mandibular projection. The facial artery crossed inferior
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mandibular border at 74.6 ±6.8%. Its diameter was gradually decreased from 3.9 ±0.7 mm at
origin to 3.4 ±0.8 mm at submental branch and 2.8 ±0.7 mm at mandibular border.
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The submental artery ran toward gnathion for 63.9 ±12.0 mm on average. Posterior
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(proximal) part of the artery was obscured by superficial lobe of submandibular gland. The
separation between the two was challenged by vascular connection formed by multiples
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glandular branches from facial and submental arteries. Each glandular branch was carefully
distinguished from perforators supplying lymph nodes. The former was cut adjacent to the
gland whereas the latter were kept entirely as lymph node pedicles. Distal part of submental
artery arose from the gland then traversed and superimposed with anterior belly of digastric
muscle (ABDM). Majority of them, 33 branches (82.5%), lied deep to the muscle defined as
deep type and the rest lied superficially defined as superficial type (Fig 3). The submental
artery usually enveloped ABDM, one side by the artery itself and another side by its branches
originated just before the artery superimposed by the muscle. The envelopment complicated
typing of submental arteries that eventually resolved by microscopic examination in some
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case.
Each submental artery branched off 2 to 6 perforators, 3.8 in average (Table II). The study
counted 153 submental perforators. Their mandibular projections ranged from 60.9% to
21.7%, beyond posterior border of ABDM. Only 124 branches (81.0%) was confirmed under
microscopy to supply lymph nodes. Half of those, 61 branches (49.6%), were originated deep
to ABDM (Table III). They extended beyond deep zone to supplied the nodes in medial,
superficial and lateral zones. Some of them perforated through ABDM from deep zone to the
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nodes in superficial zone (Fig.3). The rests of perforators were originated in lateral (36.6%),
superficial (9.8%) and medial zone (4.1%). The perforators supplying submandibular nodes
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had significantly larger diameter comparing to those supplying submental nodes, 0.59 ±0.22
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mm versus 0.47 ±0.18 mm (Table IV).
The lymph nodes
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Serial tracing under microscopy identified 174 lymph nodes from 40 flaps. The number was
comprised of 124 nodes (71.3%) from submental group, 48 nodes (38.7%) from
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submandibular group and 2 nodes (2.1%) remained unidentifiable (Table V). Average
number per flap was 4.4 ± 1.9 nodes. Of these, 3.1 ± 1.7 nodes were submental group and 1.2
± 0.9 nodes were submandibular group (Table VI). Submandibular group has a significantly
larger size than submental group, 5.6 ±2.5 mm versus 3.9 ±1.7 mm (Table IV). Classified by
quarter from Q1 ~ Q4, the nodes were distributed 9.2%, 24.1%, 28.2%, and 38.5%,
respectively (Table V). Submandibular group was concentrated in Q4 accounted for 93.8%
(45 in 48) of submandibular group. In this area, the group also predominated over submental
group and contributed 67.1% (45 of 67 nodes) of all nodes in Q4. The group were
superimposed by submandibular gland occupying much of Q3 ~ Q4. The glands nevertheless
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were well-encapsulated and appeared surgically separable from superimposed nodes.
Submental group, 124 nodes, was distributed in every quarters 13.1%, 34.4%, 37.1% and
16.4% from Q1 ~ Q4, respectively (Table V). They were subdivided by ABDM into 68 nodes
(54.8%) in lateral zone (Table III). The rests: 31 nodes (25.0%) in superficial, 13 nodes
(10.5%) in deep and 12 nodes (9.7%) in medial zone. All of 13 deep nodes were coincided
with deep type submental artery (Fig. 3b, 3d). The lateral nodes were the most visually
distinct during lateral surgical approach. However, their arterial supplies were not always
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distinct as well since they were not confined in lateral zone. Twenty of 68 lateral nodes were
supplied by perforators from the deep zone. As a result, only 46 nodes, (37.1%) of all
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submental nodes were definitely “free” from ABDM (labelled as LF in Fig. 3, 4). The free
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submental node was found inconsistently, 1.2 ± 1.1 by average. The fascia investing over
ABDM were thinner than capsule investing submandibular gland. The deep lymph nodes and
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deep perforators appeared very close to the fascia. Superficial group, on the other hand,
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showed varied proximity to ABDM due to amount of subcutaneous fat (Fig. 4d, 4e).
Discussion
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Reliable lymph node identification
Previous MRI study [5] excluded lymph nodes smaller than 1.0 mm from the study due to
limitation of MRI resolution. Our study revealed that all of lymph node in this area were
larger than 1.0 mm, hence supporting validity of previous MRI data. However, their average
number of lymph node per flap; 7.2 ± 2.4, were significantly higher than ours; 4.4 ± 1.9,
counted from microscopic serial section. Such difference could be attributed partly to our
harvest process under unaided eyes. The harvest may miss some of submandibular lymph
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nodes that located deep in subcutaneous tissue near the origin of facial artery. On the other
hand, MRI study did not verify the source of blood supply of each lymph node and virtual
demarcation of flap area by software appeared indefinite. MRI-based counting might
unintentionally include lymph node other than submental and submandibular groups.
Focusing on submental group alone, average numbers in each flap were consistent across
studies, 2.9 ± 1.5 by our study, 3.0 ±0.6 [6] and 3.3 ±1.5 [7]. Hence, the actual number of
submandibular group remains debatable.
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The optimal area for vascularized submental lymph node flap
Recent study [5] showed that lymph nodes, disregarded of their arterial supply, were
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concentrated in central quarter (Q2 ~ Q3) comprising 61% of all nodes. Our study located
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52.3% (Table V); 2.3 ± 1.4 nodes by average in the same area (Table VI). We also showed
that harvesting Q3 and Q4 (posterior half) would obtain about two-third of all nodes, 2.9 ±
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1.4 by average whereas harvesting Q2 to Q4 (posterior three quarters) would obtain most of
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the nodes. Asuncion et al. [5] also showed close relationship between lymph nodes and
submandibular gland implying the latter as optimal landmark for harvest area. It is
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noteworthy that large proportion of the Q4 lymph nodes superimposed by the gland were
submandibular group, 67.1% of Q4 nodes (Table V). Decision to harvest Q4 nodes therefore
should include facial artery for viability of submandibular group. Lymph node perforators
that superimposed by the gland should be differentiated carefully from glandular branches,
1.5 branches by average [11]. On the other hand, inclusion of the facial artery would increase
pedicle length by 44.6  16.5 mm (Table I).
A patient who cannot afford to sacrifice the facial artery should avoid Q4 due to large
contribution of facial artery to the area. The harvest of Q2 ~ Q3 or Q1 ~ Q3 should obtain 2.2
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±1.4 or 2.6 ±1.5 submental nodes, respectively with neglectable number of submandibular
group.
The dilemma to sacrifice anterior belly of digastric muscle (ABDM)
ABDM is usually sacrificed during harvest of submental lymph node flap especially when it
obscured the submental arteries that, according to our data, would occur 82.5% of the cases.
The number are very close to Magden et al. [8] at 81%, but slightly different from Faltaous et
al. [9] at 70%. Previous study [6] showed mandibular projection of anteriormost submental
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perforators at 41%. They concluded that submental perforators were limited anteriorly by
posterior (lateral) border of ABDM. Hence surgical exploration beyond posterior border of
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ABDM to gain more viable lymph node seem futile. Our data nevertheless showed a slightly
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more anterior version of mandibular projection of submental perforator. Vascular injection
and serial sectioning revealed that anteriormost submental perforators extended beyond
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posterior border of ABDM up to 21.5% of mandibular projection. Some perforated through
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ABDM from its deep zone to supply submental lymph nodes located superficial to the
muscle.
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Ramification of the submental artery diminished the possibility to preserve ABDM as it
would compromise lymph node’s arterial supply related to the muscle. Firstly, a plan to
preserve ABDM in case of superficial type submental artery seems futile because the typing
of the artery would be difficult by conventional surgical procedures. According to our study,
major artery had only slightly larger diameter than its branches so that the typing had to be
resolved by total exposure of ABDM or microscopic sections. Secondly, Number of lymph
node in deep zone might be trivial, 10.6% of submental group, but the deep zone harbored
much of perforators supplying the node in every zones. Definitely free submental nodes; non-
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overlapped node and perforators, was reduced and found inconsistently in the flap.
Nonetheless, the attempt to separate the perforators from the muscle required great cares.
Muscular fascia investing ABDM was thinner than submandibular gland capsule.
Limitation of the study
Our methods were insufficient to resolve two issues: firstly, debatable number of
submandibular lymph nodes that might be a result of inadequate dissection. Secondly,
potential collateral or coalescent arterial supply to a lymph node. Our dissection simulated
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actual flap harvest that limited exploration on ipsi- and contralateral arterial supply to the
nodes. We suggest “en bloc” approach in further study harvesting both sides of cervical zone
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Ia Ib simultaneously with part of mandible. The approach should preserve topographical
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accuracy of all structures, especially submandibular gland that usually disoriented during
dissection processes.
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Conclusion
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Lymph nodes were concentrated in posterior three quarter of the flap; therefore, harvest area
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could be reduced accordingly. Facial artery had significant contribution supplying lymph
nodes in posterior quarter of the flap. Sacrifice of facial artery would benefit both in viability
of the nodes and increasing mobility of the flap. Alternatively, submental-only design should
select central quarters or anterior three quarter of the flap predominated by the submental
lymph nodes. ABDM should be sacrificed to secure arterial supply of the submental nodes
due to intimate relationship of the perforator supplying the node with the muscles.
Acknowledgment
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For dissection part, we wish to thank Suphalerk Lohasammakul, Warit Chongkolwatana,
Phattarapong Predapramote and Kittipich Sangkamard, Department of Anatomy, Faculty of
Medicine Siriraj Hospital, Mahidol University for their excellent surgical skill.
For microscopy part, we wish to thank all staffs in Microtechnique Unit, Department of
Anatomy for painstaking production of serial microscopic sections and Chanagun Tounkhrua
for industrious tracing and identification of all lymph nodes.
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Abbreviation list
VSLN flap, vascularized submental lymph node flap
VLNT, vascularized lymph node transplantation
LVA, lymphovenular anastomosis
ABDM, anterior belly of digastric muscle
SMG, submandibular gland
Q, quarter
MP, mandibular projection
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References
1. Akita S, Mitsukawa N, Kuriyama M, et al: Comparison of vascularized supraclavicular
lymph node transfer and lymphaticovenular anastomosis for advanced stage lower extremity
lymphedema. Ann Plast Surg 74:573-9, 2015
2. Ozturk CN, Ozturk C, Glasgow M, et al: Free vascularized lymph node transfer for treatment
of lymphedema: A systematic evidence-based review. J Plast Reconstr Aesthet Surg 69:123447, 2016
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3. Nguyen DH, Chou PY, Hsieh YH, et al: Quantity of lymph nodes correlates with
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improvement in lymphatic drainage in treatment of hind limb lymphedema with lymph node
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flap transfer in rats. Microsurgery 36:239-45, 2016
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4. Patel KM, Chu SY, Huang JJ, et al: Preplanning vascularized lymph node transfer with
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duplex ultrasonography: an evaluation of 3 donor sites. Plast Reconstr Surg Glob Open 2:e193,
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5. Asuncion MO, Chu SY, Huang YL, et al: Accurate Prediction of Submental Lymph Nodes
Using Magnetic Resonance Imaging for Lymphedema Surgery. Plast Reconstr Surg Glob Open
6:e1691, 2018
6. Tzou CH, Meng S, Ines T, et al: Surgical anatomy of the vascularized submental lymph
node flap: Anatomic study of correlation of submental artery perforators and quantity of
submental lymph node. J Surg Oncol 115:54-59, 2017
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7. Cheng MH, Huang JJ, Nguyen DH, et al: A novel approach to the treatment of lower
extremity lymphedema by transferring a vascularized submental lymph node flap to the
ankle. Gynecol Oncol 126:93-8, 2012
8. Magden O, Edizer M, Tayfur V, et al: Anatomic Study of the Vasculature of the
Submental Artery Flap. Plastic and Reconstructive Surgery 114:1719-1723, 2004
9. Faltaous Adel A YRJ: The Submental Artery Flap: An Anatomic Study. Plast Reconstr
Surg 97:56-60, 1996
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10. Lohasammakul S, Turbpaiboon C, Chompoopong S, et al: Vascular Nature and Existence
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Reconstruction. Ann Plast Surg 78:723-727, 2017
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11. Li L, Gao X-l, Song Y-z, et al: Anatomy of arteries and veins of submandibular glands.
Chinese Medical Journal 120:1179-82, 2007
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Figure legends
Fig. 1. Photographs show 4 steps of study method. (a) The flap area was drawn from
gnathion to gonion demarcating mandibular and medial borders. Then 3 perpendicular lines
were drawn to divided the flap into 4 quarters, Q1 ~ Q4. (b) The flap was harvested by
lateral approach. The anterior belly of digastric muscle was cut from mandible and reflected.
(c) Once removed, the flap was dissected further to expose the facial artery (FA), the
submental artery (SA), perforators (P) and lymph nodes (L). Then the flap was fixed with
10% formalin. (d) The entire flap was sliced at 2-mm thick and subjected to histological
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processes. Mylohyoid (MH), submandibular gland (SMG), anterior belly of digastric muscle
(DM).
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Fig. 2. (a) Inferior view diagram shows measurements of the facial artery; the length from its
origin to the origin of the submental artery (FL1), the length from the origin of the submental
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artery to mandibular border (FL2), the diameter at origin (F1), the diameter at the origin of
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the submental artery (F2), and the diameter at the crossing point over mandibular border
(F3). The submental artery was measured for total length (SL) and diameter at the origin
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(S1). The positions relative to mandibular border (mandibular projection, MP) were
measured at F3, S1, location of the lymph nodes and the perforators. The percentage of
mandibular projection (MP%) are approximately coincided with Q1 ~ Q4 at 0~25%, 25~50%
50~75% and 75~100%, respectively. (b) Coronal section diagram shows zoning of the flap
by anterior belly of digastric muscles (DM) medial (M), superficial (S), deep (D) and lateral
(L) zones. Submandibular gland (SMG).
Fig. 3. Diagrams of the submental artery (SA) comparing between the superficial (a, c) and
the deep type (b, d) in aspect of distribution of the submental perforators and submental
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lymph nodes. The superficial type submental artery harbors the submental nodes in 3 zones
relative to anterior belly of digastric muscle (DM); medial (M), superficial (S) and lateral (L)
but not in deep zone (D). The latter was only found in the deep type submental artery. The
deep perforators of the deep artery (b, d) are either circumvent or perforate the muscle to
supply the superficial node located on the opposite side. Free lateral node (LF) is located
where related perforator is also not overlapped with the muscle. Facial artery (FA),
submandibular gland (SMG), hyoid bone (H), mylohyoid muscle (MH), platysma (PL).
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Fig. 4. Micrographs show variations in topographical relationship between the submental
lymph nodes and the perforator supplying them. (a) Free lateral node (LF) is located where
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both node and entire perforator (arrowhead) are lateral to the anterior belly of digastric
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muscle (DM). (b) Lateral node (L) is supplied by perforator originated deep to the muscle. (c,
e) Deep perforators circumvent the muscle to supply medial (M) and superficial nodes (S).
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(d) Deep perforator perforates the muscle to supply superficial node (S). (f) Perforator and
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the node are both in deep zone. Perforator (arrowhead), platysma (PL), mylohyoid (MH).
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Table I. Characteristics of the Mandible, the Facial Artery and the Submental Artery
Length (mm)
Facial artery
Diameter (mm)
FL1 + FL2:
68.6  19.9
F1:
3.9 0.7
FL1:
44.6  16.5
F2:
3.4 0.8
FL2:
25.9  8.2
F3:
2.8 0.7
SL:
63.9  12.0
S1:
2.4 0.7
Submental artery
The data are represented by mean standard deviation
FL1, the length of the facial artery from its origin to the origin of the submental artery
FL2, the length of the facial artery from the origin of the submental artery to mandibular border
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F1, the diameter of the facial artery at origin
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F2, the diameter of the facial artery at the origin of the submental artery
F3, the diameter of the facial artery at the crossing point over mandibular border
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SL, the total length of the submental artery
S1, diameter of the submental artery at the origin
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Table II. Mandibular Projection of the Facial Artery, the Submental Artery and
Submental Perforators
Mandibular projection
Inferior mandibular border
mm
%
98.8  6.1
100
(gnathion to gonion)
Facial artery
At F3 (n = 40)
74.6  6.8
75.6  6.6
Submental artery
At S1 (n = 40)
77.0  9.0
78.2  9.3
1st (n = 40)
59.8  9.1
60.9  10.4
2nd (n = 38)
50.5  9.6
51.4  10.4
3rd (n = 35)
40.0  11.3
40.6  11.9
4th (n = 19)
34.0  9.6
34.5  10.4
5th (n = 14)
28.6  8.9
29.0  8.4
6th
21.5  5.3
21.7  4.7
Submental perforator
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(n = 7)
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The data are represented by mean standard deviation
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At F3, at the crossing point over mandibular border
At S1, at origin of the submental artery
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Table III. Zoning of Submental Perforators supplying the lymph nodes and the Submental
Lymph Nodes According to Relationship with Anterior Belly of Digastric Muscles
(ABDM)
Zoning by ABDM (count, %)
The perforators supplying the
submental nodes (n = 124)
Submental nodes (n = 124)
Medial
Deep
Superficial
Lateral
5 (4.1%)
61 (49.6%)
12 (9.8%)
45 (36.6%)
12 (9.8%)
13 (10.6%)
31 (25.2%)
67 (54.5%)
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Table IV. Comparisons Between Submandibular Lymph Nodes and Submental Lymph
Nodes in Terms of Node’s Size and Diameter of The Perforator Supplying Them
All
nodes
(n = 174)
Submandibular
nodes
(n = 48)
Submental
nodes
(n = 124)
Lymph nodes
size (mm)
4.4  2.2
5.6  2.5
3.9  1.9
0.00005
Perforators
diameter (mm)
0.50  0.20
0.59  0.22
0.47  0.18
0.00670
Value are in mm, represented by mean standard deviation
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P value
(P < 0.05, 2-tailed)
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Table V. Distribution of the Lymph Nodes by Quarter (Q)
Lymph node count (nodes, %)
All
Submandibular
Submental
2
(n = 174)
(n = 48)
(n = 124)
Q1
Q2
Q3
Q4
16
42
49
67
(9.2%)
(24.1%)
(28.2%)
(38.5%)
0
0
3
45
(0%)
(0%)
(6.3%)
(93.8%)
16
42
46
20
(13.1%)
(34.4%)
(37.1%)
(16.4%)
lymph nodes were unclassifiable.
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Table VI. Average number of the Lymph Nodes by Quarter (Q)
Lymph node by average
All Q
All
Submandibular
Submental
2
Q1 ~ Q3
Q2 ~ Q3
Q3 ~ Q4
(central quarters)
(posterior half)
(n = 174)
4.4  1.9
2.7  1.5
2.3  1.4
2.9  1.4
(n = 48)
1.2  0.9
-
-
1.2  0.9
(n = 124)
3.1  1.7
2.6  1.5
2.2  1.4
1.7  1.3
lymph nodes were unclassifiable
Average
is represented by mean standard deviation
neglectable
numbers
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Fig. 1. Photographs show 4 steps of study method. (a) The flap area was drawn from gnathion to gonion
demarcating mandibular and medial borders. Then 3 perpendicular lines were drawn to divided the flap into
4 quarters, Q1 ~ Q4. (b) The flap was harvested by lateral approach. The anterior belly of digastric muscle
was cut from mandible and reflected. (c) Once removed, the flap was dissected further to expose the facial
artery (FA), the submental artery (SA), perforators (P) and lymph nodes (L). Then the flap was fixed with
10% formalin. (d) The entire flap was sliced at 2-mm thick and subjected to histological processes.
Mylohyoid (MH), submandibular gland (SMG), anterior belly of digastric muscle (DM).
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Fig. 2. (a) Inferior view diagram shows measurements of the facial artery; the length from its origin to the
origin of the submental artery (FL1), the length from the origin of the submental artery to mandibular border
(FL2), the diameter at origin (FΦ1), the diameter at the origin of the submental artery (FΦ2), and the
diameter at the crossing point over mandibular border (FΦ3). The submental artery was measured for total
length (SL) and diameter at the origin (SΦ1). The positions relative to mandibular border (mandibular
projection, MP) were measured at FΦ3, SΦ1, location of the lymph nodes and the perforators. The
percentage of mandibular projections (MP%) are approximately coincided with Q1 ~ Q4 at 0~25%, 25~50%
50~75% and 75~100%, respectively. (b) Coronal section diagram shows zoning of the flap by anterior belly
of digastric muscles (DM) medial (M), superficial (S), deep (D) and lateral (L) zones. Submandibular gland
(SMG).
80x160mm (600 x 600 DPI)
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Fig. 3. Diagrams of the submental artery (SA) comparing between the superficial (a, c) and the deep type
(b, d) in aspect of distribution of the submental perforators and submental lymph nodes. The superficial
type submental artery harbors the submental nodes in 3 zones relative to anterior belly of digastric muscle
(DM); medial (M), superficial (S) and lateral (L) but not in deep zone (D). The latter was only found in the
deep type submental artery. The deep perforators of the deep artery (b, d) are either circumvent or
perforate the muscle to supply the superficial node located on the opposite side. Free lateral node (LF) is
located where related perforator is also not overlapped with the muscle. Facial artery (FA), submandibular
gland (SMG), hyoid bone (H), mylohyoid muscle (MH), platysma (PL).
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Fig. 4. Micrographs show variations in topographical relationship between the submental lymph nodes and
the perforator supplying them. (a) Free lateral node (LF) is located where both node and entire perforator
(arrowhead) are lateral to the anterior belly of digastric muscle (DM). (b) Lateral node (L) is supplied by
perforator originated deep to the muscle. (c, e) Deep perforators circumvent the muscle to supply medial
(M) and superficial nodes (S). (d) Deep perforator perforates the muscle to supply superficial node (S). (f)
Perforator and the node are both in deep zone. Perforator (arrowhead), platysma (PL), mylohyoid (MH).
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