Hilar Vessels of the Submandibular and Upper Jugular Neck Lymph Nodes: Anatomical Study for Vascularized Lymph Node Transfer to Extremity Lymphedema.

Objectives: Vascularized lymph node transfer for lymphedema is an emerging method of treatment. Vascularized lymph nodes have been harvested from a number of donor sites, that is, groin, axilla, and neck. There is a concern that harvesting nodes from the groin and axilla may lead to donor site lymphedema. This risk is greatly reduced in harvesting from the neck due to the abundant supply of lymph nodes here. In this cadaver study, we describe the submandibular and upper jugular groups of lymph nodes, demonstrate their hilar vessels, their source pedicles and drainage veins, quantified and qualified these groups of lymph nodes and their relationship to surrounding structures. Methods: Five fresh adult cadaver necks (10 sides) were dissected looking at the submandibular and upper jugular neck nodes under the microscope. We carried out vascularized lymph node transfer of upper jugular nodes from the neck to the groin of 1 patient with stage II lower extremity lymphedema and transferred vascularized submandibular nodes from the neck to the upper arm in 1 patient with stage II upper extremity lymphedema. Results: There was a mean of 3.2 (range, 1-5) lymph nodes in the submandibular group and a mean of 4.1 (range, 2-6) lymph nodes in the upper jugular group. The submandibular nodes were perfused by branches of the facial artery, that is, glandular and/or facial branches and/or submental artery in various permutations. The upper jugular nodes were perfused by the sternocleidomastoid artery, which branches from the superior thyroid artery (70%) or emerges directly from the external carotid artery (30%). Hilar veins were found to drain into surrounding larger draining tributary veins and ultimately into the internal jugular vein. At 1-year follow-up, there was a considerable decrease in girth circumference in our patients, no episodes of cellulitis after surgery, with subjective improvement in limb heaviness and skin pliability. Conclusions: This knowledge of hilar blood supply will aid in transferring a lymphatic flap with intact microcirculation. When harvesting the submandibular nodes or upper jugular nodes, it is essential to harvest them based on their source pedicles, that is, facial artery and sternocleidomastoid artery, respectively, to supply live nodes to the recipient lymphedematous limb.