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Page 2 of 9 Giacalone et al. Plast Aesthet Res 2023;10:22 https://dx.doi.org/10.20517/2347-9264.2022.115

[5]
to drain into the systemic circulation, LVA has an immediate positive impact . Furthermore, as LVA does
not require harvesting of existing lymphatic tissue, the latter carrying an inherent risk of donor-site
[6]
lymphedema, it is also a safe procedure . Another advantage of LVA is that it requires only a small incision
in the skin that can be performed under loco-regional anesthesia, resulting in a very low complication rate.
Thanks to these advantages, LVA is particularly suitable as a first-line surgical option for the treatment of
[7-9]
BCRL . However, one must be aware that experience, together with specialized equipment, are
prerequisites for a good patient outcome [10,11] .

SURGICAL TECHNIQUE
The earliest series of LVAs in humans were described several decades ago [12,13] , but the technique in current
[14]
use was first developed by Koshima . Supermicrosurgery refers to the handling of vessels with a diameter
less than 1 mm, but the lymphatic vessels targeted in LVA are usually considerably smaller, between 0.20
and 0.80 mm in diameter. Several factors play a role in the outcome, including the incision location, the size
and configuration of vessels, and the type of anastomosis.

An LVA skin incision is, on average, 2 cm in length and, despite directly interrupting superficial lymphatic
vessels, does not provoke iatrogenic lymphedema. The location of the incision is based on the identification
of lymphatics and veins during pre-operative assessment. Intra-operatively, the choice of suitable vessels can
be challenging. Ideally, equally-sized vessels and/or vessels with favorable lymph-to-blood pressures should
be used for the creation of the LVA. However, in case of a mismatch, several different approaches are
[16]
[17]
available, ranging from venous-branch-plasty and interposition to funnelization [Figure 1A]. The
[15]
choice of a favorable recipient vein is also crucial . It has been suggested that a relatively smaller
[18]
[5]
subcutaneous vein should be selected for LVA when the lymphatic vessels are abnormally dilatated .
[19]
Particular importance should be paid to the prevention of blood reflux, for instance, by valvuloplasty ,
although found no adverse effect on the outcome after blood reflux through anastomosis.
[20]
The efficacy of LVA is also determined by the quality of available lymphatics. ‘Normal’ or ‘ectatic’ lymph
vessels are preferred when creating a functioning LVA [11,21] , although the true histopathology of the vessel is
rarely known intra-operatively. An intima-to-intima approach is essential to prevent post-operative
occlusions . Intraluminal insertion of a custom-made nylon stent can help to avoid picking up the back
[5]
[22]
wall, as well as to prove the patency of the LVA [Figure 1B].
The patency of the LVA after anastomosis can now be easily confirmed through washout by lymphatic fluid
in the vein and/or by observing indocyanine green (ICG) in the vein [Figure 2]. Indeed, thanks to the
[23]
improvement in operative microscopes in terms of magnification and built-in infrared cameras, intra-
operative visualization of lymphatic vessels is now common practice. Any leak can also be easily traced with
the ICG module and should be rectified in order to prevent thrombosis. Before closing the incision, the
position of the LVA and the vessels should be checked in order to optimize the long-term patency of the
anastomosis: traction or aberrant position of the new construction should be avoided.

Depending on the available vessels preoperatively, a variety of anastomotic configurations can be created
with the aim of increasing maximal lymphatic drainage into the venous system [23-25] . However, in the large
majority of cases, an end-to-end anastomosis will be performed. Other configurations, including end-to-
side, side-to-end, and side-to-side, are sometimes required, depending on the venous pressure and
[26]
anatomy .