The dissection starts at the axillary region.
The fibrosis is dissected and the thoracodorsalis vessels are identified.
Vascular branches, with suitable sizes for micro anastomosis, are prepared.
If a neuroma is encountered or chronic pain and palsy are present, external neurolysis is performed.
The thoracobrachial space must be decompressed.
The extension of the flap needed is estimated to fill the lymphatic tissue and bridge the scarred tissue.
The VGEF-c produced at the lymphnodes promotes lymphangiogenesis to reconnect the distal and proximal systems.
Three different lymph nodes flaps can be transferred:
- the external inguinal flap,
- the thoracic flap,
- the cervical flap
The superficial inguinal lymph node flap starts with an incision performed over a line located between the iliac crest and the pubis.
The length of the incision depends on the flap size needed to fill the defect. The subcutaneous tissue is incised to the depth of the fascia cribiformis, where a superficial diagonal vein can be found. The fatty tissue located deeper to this superficial fascia and superficially to the muscular aponevrosis contains lymph nodes that can be transferred on the circumflex iliac vessels. This pedicle can be dissected and the flap can be elevated around the isolated vessels. Inferiorly, the inguinal crest is a very important limit of the dissection, and preserving the deep lymph nodes is very important to prevent secondary lymphedema at the donor site.
The flap is then transferred to the recipient site at the axillary area, with microsurgical technique.