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Microsurgical Procedures: Lymphovenous Anastomosis Techniques

Key Points Lymphovenous bypass (LVB) usually requires anastomosing lymphatic vessels less than 0.8 mm in diameter to small subdermal venules. A high-resolution microscope, super-fine instruments and sutures, and the training of supermicrosurgery are the basic requirements for the success of this technique. Patients with early-stage lymphedema, especially involving upper limb lymphedema, with functioning lymphatic vessels are the preferred candidates for LVB. Preoperative detection of the available…

Microsurgical Procedures: Minimizing Donor Site Morbidity Following Vascularized Lymph Node Transfer

Key Points Superficial inguinal lymph nodes targeted for harvest lie between the groin crease and inguinal ligament. The vascular supply of these nodes is typically the superficial circumflex iliac artery. These nodes typically drain the lower abdomen; however, there are exceptions and in certain cases may contribute to drainage of the lower limb. Reverse lymphatic mapping (RLM) is a technique that allows the surgeon to identify…

Mesenteric Vascularized Lymph Node Transfer

Key Points The small bowel mesentery represents a donor site for vascularized lymph node transfer that contains numerous and redundant lymph nodes and has reliable anatomy with minimal donor site morbidity. The small bowel mesenteric lymph node flap can usually be readily outlined before flap harvest through the use of transillumination, including its lymph nodes, their relationship to the vascular pedicle, and the remaining vascular supply…

Treatment of Lymphedema: Vascularized Omental Lymphatic Transfer

Key Points Intraoperative mapping of the right gastroepiploic lymphosome is valuable to identify critical flap components. No-touch flap elevation will prevent damage to the flap lymphatics and microvasculature. Harvesting additional capillary networks can minimize venous congestion. Additional vascular anastomoses may be required to mitigate venous congestion. Introduction Although lymphatic surgery has been practiced for over 100 years, advances in lymphatic comprehension, instrumentation, and imaging have resulted…

Microsurgical Procedures: Vascularized Lymph Node Transfer from the Thoracodorsal Axis

Key Points The axillary donor site has the highest reported incidence of lymphedema. Preoperative imaging facilitates surgical planning and establishes a baseline for postoperative comparison. Reverse lymphatic mapping identifies lymphatic drainage patterns, identifying lymph nodes for transfer while minimizing the risk of donor site lymphedema. Use of turbocharge, supercharge, and reverse-flow anastomoses can ensure adequate blood supply to the lymph nodes and facilitate flap insetting in…

Microsurgical Procedures: Vascularized Lymph Node Transfer from the Supraclavicular Region

Key Points Harvesting lymph nodes from the axillary or groin region may cause secondary lymphedema of the upper or lower extremity. The main advantage of supraclavicular nodes harvest is minimal risk of secondary lymphedema. The flap is designed with or without a skin flap in a horizontal orientation above the clavicle. A freestyle free flap based on the transverse cervical artery and vein and branches of…

Microsurgical Procedures: Vascularized Lymph Node Transfer from the Submental Region

Key Points The upper margin of the flap is designed at the lower border of the mandible to result in an inconspicuous scar. Preoperative Doppler ultrasound and magnetic resonance imaging are helpful for evaluating the number of sizable lymph nodes and the course of the facial artery. The indications for submental vascularized lymph node flap transfer include Cheng’s Lymphedema Grades 2–4, total obstruction of the lymphatic…

Vascularized Lymph Node Transfer from the Groin

Key Points The vascularized lymph node flap transfer from the groin was first introduced by Clodius in 1982 in two clinical cases. Animal studies described the vascularized lymph node flap as an effective technique for the treatment of lymphedema prior to most clinical studies. The vascularized groin lymph node can be independently transferred to the axilla, elbow, and wrist with promising results. The vascularized groin lymph…

Recipient Site Choices and Donor Option Considerations for Vascularized Lymph Node Transfer

Key Points A number of different donor sites exist for vascularized lymph node transfer that have near-equivalent success rates in improving the condition of patients suffering from lymphedema. Donor site selection should be based on surgeon comfort and experience, taking into account patient expectations and availability of donor sites, and with a thorough understanding and ability to manage complications. Recipient site selection can be placed proximally,…

Overview of Surgical Techniques

Key Points Reductive procedures (direct excision with skin grafting or liposuction) alone or as an adjunct are effective in gross reduction of volume; however, they carry significant morbidity. Direct excision with skin grafting is reserved for the most extreme cases of lymphedema in which function and activities of daily living are severely affected. Liposuction for reduction of excess adipose deposition requires lifelong postoperative compression garments. Physiologic…

Lymphedema Risk Reduction and Management

Key Points Lymphedema is more than mechanical insufficiency due to reduced transport capacity. Lymphedema is an inflammatory edema associated with an increase in the adipose content of the subcutaneous layer and interstitial fibrosis. Complete decongestive therapy is an accepted and effective combination of techniques that decongests the soft tissue swelling associated with lymphedema. Multimodal treatment approaches, including manual lymphatic therapy, compression bandaging, exercise, intermittent pneumatic compression,…

Clinical Evaluation of Lymphedema

Key Points The clinician’s role in lymphedema treatment and management is to provide the best diagnosis, treatment plan, and advice as to what will be the most appropriate approach; taking into consideration the stage and severity of lymphedema together with psychosocial status can help predict the amount of participation the patient (and/or caregiver) will be able to contribute to the process. Evidence in the literature supports…

Refining Planning of Lymphedema Surgery of the Extremities Using MRI and CT Imaging Techniques

Key Points Lymphedema (surgical) treatment is nowadays tailored to the patient’s needs and even more specifically to the local needs in one affected limb. Lymphoscintigraphy and near-infrared fluoroscopy are baseline imaging techniques for lymphedema, but both have limitations, especially for surgical planning in more advanced cases. Magnetic resonance (MR) lymphography permits us to have a full mapping of the lymphedematous limb as to the local needs,…

ICG Lymphography and Its Application

Key Points Indocyanine green (ICG) lymphography clearly visualizes superficial lymph flows in real time without ionized radiation exposure. Dynamic ICG lymphography, dual-phase fluorescent image observation, is important to maximize the efficacy of ICG lymphography for lymphatic mapping and appropriate severity staging. ICG lymphography findings change from “linear,” to “splash,” to “stardust,” and finally to “diffuse” pattern with the progression of lymphedema. ICG lymphography allows pathophysiologic severity…

Lymphoscintigraphy Interpretation, Staging, and Lymphedema Grading

Key Points Lymphoscintigraphy is an objective and reliable imaging modality for diagnosing lymphedema, categorizing its severity, and guiding appropriate treatment. The diagnostic utility of lymphoscintigraphy depends upon meticulous technical performance and correct image interpretation. The main drawback of lymphoscintigraphy is the lack of standardized protocols, making comparisons among the studies difficult. Several lymphoscintigraphic staging or scoring systems have been proposed, with variable clinical applications. The recently…

Primary Lymphedema with Concomitant Vascular and Lymphatic Lesions

Key Points Primary extremity lymphedema is a debilitating disease with a reported incidence of 1–3 in every 10,000 births, and it may present with concomitant vascular lesions or retroperitoneal lymphangiomatosis with chylous ascites. The diagnosis of primary extremity lymphedema includes history, physical examination, lymphoscintigraphy, and indocyanine green lymphography. Doppler ultrasound and computed tomography angiography are the key evaluation tools for concomitant vascular lesions. Magnetic resonance imaging…

Pathophysiology and Molecular Research in Lymphedema

Introduction Lymphedema can develop as a result of developmental or genetic abnormalities intrinsic to the lymphatic system (primary lymphedema) or secondary to extrinsic factors (infections, trauma, malignancy, obesity, etc.) that impair lymphatic function. Although the common denominator in both lymphedema subtypes is inadequate lymphatic function, the pathophysiology of the disease is complex, and the phenotype that is displayed clinically is highly variable. Recent research has shed…

Animal Study and Cadaver Dissection of Lymphedema

Key Points Lymphangiogenesis occurs in four distinct regular phases: lymphatic competence, lymphatic commitment, lymphatic speciation, and lymphatic maturation. Vascular endothelial growth factor C and vascular endothelial growth factor receptor-3 signaling are essential for lymphangiogenesis. Animal models of secondary lymphedema have expanded our understanding of its pathogenesis and have facilitated the advancement of its treatment. Animal models allow further investigation of the physiologic mechanism, molecular basis, and…

Anatomy and Structural Physiology of the Lymphatic System

Key Points Precise knowledge about normal lymphatic anatomy in the upper and lower extremities can empower practitioners to distinguish structural changes occurring in lymphedema. Lymphatic anatomy in lymphedema changes substantially with the deterioration of superficial lymph collecting vessels. Lymphedema can be caused by restriction of outflow from the original pathway through the axilla or inguinal region and is not always associated with changes in lymphatic drainage…

Introduction to Lymphedema Surgery: Principles and Practice

“Declare the past, diagnose the present, foretell the future.” –Hippocrates. Overview The surgical treatment of lymphedema has evolved tremendously since the early 21st century. With the advances in microsurgical techniques, new options are available for patients suffering from the physical and emotional sequelae of symptomatic lymphedema. The development of lymphatic microsurgery occurred much later than other areas in reconstructive microsurgery. This is likely due to a…