title: Surgical anatomy of the vascularized submental lymph node flap: Anatomic study of correlation of submental artery perforators and quantity of submental lymph node.
abstract: BACKGROUND
  Harvesting the submental flap for vascularized lymph node transfer (VLNT) presents a challenging procedure because of, the topographic variation of the submental artery (SA) and the marginal mandible nerve (MMN) and the limited pedicle length for a free tissue transfer. The aim of this study was to evaluate surgical anatomical landmarks and variations of the submental lymph node flap (SLNF).
  
  
  METHODS
  The authors examined the characteristics and landmarks of 18 SLNF in nine fresh cadavers. The diameter, length, and caliber of the SA and its relation to bony anatomic landmarks were measured. In addition, the number of lymph nodes (LNN) was evaluated through dissection and ultrasound.
  
  
  RESULTS
  Within the designated SLNF (10 × 5 cm2), the number of LNN was on average 3 ± 0.6, with an average size of 4.5 ± 1.8 mm × 2.9 ± 1.2 mm. Projection of the LNN on the mandible, measured from the gnathion (GT, median-sagittal-plane) toward the gonion (GN, mandibular angle), was at 63.4 ± 5.8 mm (e.g., 65%) of the mandible for the first lymph node (LN), and for the following LNN was at 50.4 ± 7.7 mm (e.g., 52%), 44.0 ± 8.6 mm (e.g., 45%), and 40.50  ±  2.1 mm (e.g., 42%). The MMN consistently crossed the mandible body and the facial artery (FA) from dorso-caudal to ventro-cranial at 72 ± 5.2 mm, e.g., 75% of the mandible's length. Here, the nerve always lay superficial to the FA and was on average 0.96 ± 0.14 mm in diameter. Submental artery was located on average at 64 mm (e.g., 66%) of the mandible, with an average diameter of 1.34 ± 0.2 mm.
  
  
  CONCLUSIONS
  The submental lymph node flap has a constant vascular supply by the submental artery. Lymph node count is on average three. Lymph nodes are close to the submental artery and its perforators. Marginal mandibular nerve lies superficial to the facial artery and crosses the artery at 75% of the mandible body length (gnathion to gonion = 100%). J. Surg. Oncol. 2017;115:54-59. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Chieh Han
authors.initials: CH
authors.lastname: Tzou
authors.affiliation: Department of Systematic Anatomy, Institute of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Austria.
authors.forename: Stefan
authors.initials: S
authors.lastname: Meng
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Tinhofer
authors.initials: T
authors.lastname: Ines
authors.affiliation: Department of Systematic Anatomy, Institute of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Austria.
authors.forename: Lukas
authors.initials: L
authors.lastname: Reissig
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Ursula
authors.initials: U
authors.lastname: Pichler
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Johannes
authors.initials: J
authors.lastname: Steinbacher
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Igor
authors.initials: I
authors.lastname: Pona
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Julia
authors.initials: J
authors.lastname: Roka-Palkovits
authors.affiliation: Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rath
authors.affiliation: Department of Systematic Anatomy, Institute of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Austria.
authors.forename: Wolfgang J
authors.initials: WJ
authors.lastname: Weninger
authors.affiliation: Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Center for Tissue Engineering, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
authors.forename: Ming-Huei
authors.initials: MH
authors.lastname: Cheng
mesh_terms: D000369:Aged, 80 and over; D002102:Cadaver; D005260:Female; D006801:Humans; D008198:Lymph Nodes / Q000033:anatomy & histology* / Q000098:blood supply / Q000601:surgery; D008297:Male; D061525:Perforator Flap / Q000098:blood supply* / Q000601:surgery; D013524:Surgical Flaps / Q000098:blood supply* / Q000601:surgery; D020858:Tissue and Organ Harvesting / Q000379:methods
keywords: SLNF; VLNT; anatomy; breast cancer; facial nerve; lymph nodes; lymphedema; marginal mandible nerve; submental lymph node flap; surgical anatomy; vascularized lymph node transfer