All-star lymphatic supermicrosurgery: Multiple lymph flow diversion using end-to-end, end-to-side, side-to-end, and side-to-side lymphaticovenular anastomoses in a surgical field

Supermicrosurgery: History, Applications, Training and the Future

“…Importantly, of the patients followed up in their study, 85% were able to discontinue the use of conservative measures, with an average follow-up time of 10 years and a 69% average reduction in excess volume ( 35 ). Other studies have similarly reported positive quantitative and qualitative improvements in lymphedema following LVA ( 31, 32, 36 – 39 ). The introduction of additional techniques and refinement of the procedure will likely continue to improve outcomes in the future ( 39 ).…”

“…Other studies have similarly reported positive quantitative and qualitative improvements in lymphedema following LVA ( 31, 32, 36 – 39 ). The introduction of additional techniques and refinement of the procedure will likely continue to improve outcomes in the future ( 39 ).…”

Supermicrosurgical lymphaticovenular anastomosis vs. vascularized lymph vessel transplant - technical optimization and when to perform which

“…Theoretically, a few high-quality anastomoses (antegrade flow anticipated) should suffice, but reality often necessitates a quantity-over-quality approach. In keeping with this, the senior author (Chen WF) has demonstrated considerable clinical success when using suboptimal vessels by creating 8 to 15 LVAs per case [48,54,64] . The following are used as the procedure endpoints: (1) six hours of operative time; for experienced microsurgeons, continuing beyond this duration typically yields diminishing returns; (2) three consecutive negative incisions (i.e., no suitable lymphatics found when proceeding in a distal-to-proximal fashion); or (3) substantial drainage through LVAs causing visible limb decompression on the table [54] .…”

“…All dissected lymphatics are inspected and graded as healthy, ectatic (mild injury), contracted (moderate injury), or sclerotic (severe injury) [16,53] . Although healthy vessels are preferred, ectatic and contracted vessels can also be used when necessary to achieve a sufficient number of LVAs per case [47,54] .…”

“…When lymphatic pressure exceeds venous pressure, all configurations should work; end-to-end will often be chosen as it is the most technically straightforward. However, when the pressure gradient is unfavorable, side-to-side or end-to-side is chosen to take advantage of Bernoulli's principle [54] . Side-to-side is the more technically challenging and should be performed only if the involved vessels are 0.4 mm or more in diameter.…”