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Giacalone et al. Plast Aesthet Res 2023;10:22 https://dx.doi.org/10.20517/2347-9264.2022.115 Page 5 of 9

Figure 5. Dedicated instrument: forceps.

Figure 6. Needles ranging from 50 microns.

sclerosis of the lymphatic vessels, which are irreversible. While LVA is efficient in early-stage lymphedema,
[45]
even late-stage lymphedema, typically treated by debulking procedures or combined techniques , is
[46]
increasingly being treated using LVA [47,48] . Alternatively, lymphatic vessel transplantation can reconstruct
interrupted lymphatic pathways after axillary lymph node resection in patients with breast cancer .
[49]
In addition to arm lymphedema, breast lymphedema (BLE) is also a major sequela of breast cancer
treatments . Although an estimated one-third of all breast cancer patients develop BLE after breast-
[50]
conserving surgery with axillary lymph node intervention, its management remains poorly described. LVA
is reportedly effective for extremity lymphedema and also has proven efficacy in BLE [51,52] . While
compression therapy is a cornerstone of the treatment of extremity lymphedema, in BLE, the complexity of
breast shape causes significant difficulties. Given that patients with BLE mostly complain of (lymphatic)
congestion, a newly created lymph-to-venous bypass will give immediate relief. As men may also develop
[53]
BLE following breast cancer treatment, LVA can also be successfully performed in this group .

Axillary lymph node dissection in breast cancer treatment may also result in lymphorrhea. While lymphatic
discharge generally ceases spontaneously, intractable leakage may result in a lymphocele or fistula and
discomfort for the patient. Sclerotherapy or macroscopic ligation of the injured lymphatic vessels carries a
risk of subsequent aggravating (clinical) lymphedema. Therefore, the anastomosis of a damaged lymph
[54]
vessel to a nearby intact lymph vessel or vein is a physiological approach to restoring lymphatic drainage .
We have previously described the successful treatment of axillary lymphorrhea in a series of patients treated
by LVA for intractable lymphorrhea .
[55]

DISCUSSION
Lymphedema surgery has evolved rapidly in the last decades, largely thanks to the introduction of super
microsurgery and the application of ICG imaging. LVA is a physiological approach to lymphedema and is
now well established as an effective and minimally-invasive surgical treatment for lymphedema without risk
for complications . LVA is safe and has an immediate post-operative therapeutic effect compared to other
[8,9]