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Page 6 of 9 Giacalone et al. Plast Aesthet Res 2023;10:22 https://dx.doi.org/10.20517/2347-9264.2022.115

techniques including vascularized lymph node/vessel transfer. Consequently, LVA can now be considered
the first-line surgical treatment for lymphedema, including BCRL. However, several remaining challenges
need to be recognized.

Supermicrosurgery is technically difficult and a steep learning curve is inevitable. While major challenges
such as vessel number and/or size mismatch or difficult vessel position may be encountered preoperatively,
technological advances in equipment including microscopes and robotics allow LVAs to be performed with
greater confidence.

How many anastomoses should be performed in order to obtain maximal lymphatic drainage is still a
matter of debate [39,56] . And which factor is most important for success, the quantity or the quality (of vessels),
also remains to be unequivocally established. On average, at least 3 LVAs are performed per patient, but
[57]
factors including lymphedema stage and surgeon skill should also be taken into account . Everyday
practice, though, is determined by the number of vessels available for anastomoses and/or the
reimbursement rules imposed by authorities or insurance companies. The exact location of a skin incision is
also crucial for a good clinical result: the incision site is selected primarily on the basis of the ICG pattern,
but for technical reasons, lymphatics and veins should preferably be in close proximity. Therefore, it is of
the utmost importance that the surgeon has access to several (innovative) technologies/devices that facilitate
the identification of vessels. This will be particularly beneficial in the case of patients with dermal backflow
patterns and in patients with lymphedema of the hand, which is often an indication of degenerated
lymphatic status. In addition to the indisputable role of near-infrared cameras, nowadays, ultrasound is also
a prerequisite for good pre-operative assessment. More specifically, ultra-high frequency ultrasound can
accurately detect (histologically confirmed) functional lymphatic vessels, even in advanced cases .
[58]
Lymphoscintigraphy is a reliable tool in the visualization of lymphatic function but well-known
disadvantages, such as the two-dimensional view and the lack of projection onto anatomical landmarks, can
be overcome with the use of lympho-SPECT/CT, which provides integrated information on lymphatic
pathways . However, as with magnetic resonance imaging, these technologies do not provide real-time
[59]
information, which makes them less suitable for pre-operative planning.

Another concern is the long-term patency of an anastomosis. Efforts to prove patency should be made
during the intervention. Furthermore, post-operative patency can be confirmed by means of ICG
lymphography, lymphoscintigraphy, lympho SPECT/CT, or photoacoustic lymphangiography . According
[59]
to one report, over 70% of patients had at least one patent anastomosis 12 months after intervention .
[60]
Notwithstanding the data on functioning LVAs, there is still no consensus in the literature as to which tool
should be used to assess the post-operative clinical effect of LVAs. It should be stressed that many variables
need to be taken into account when assessing the overall outcome after LVA, among which are the number
of patent anastomoses, lymphedema staging, patient characteristics, the surgeon’s experience, and accessible
equipment.

LVA is now an established treatment option for lymphedema in various parts of the body, but is also being
increasingly used to treat a broad range of lymphatic diseases varying from lymphorrhea, a complication of
lymph node excision, to generalized lymphatic anomalies mostly encountered in pediatric patients .
[61]
However, the question of whether prophylactic LVA after lymphadenectomy actually avoids the morbidity
associated with lymphedema needs to be proven in high-quality studies with a long follow-up period [62-64] .
New technologies that focus on lymphangiogenesis also appear promising and may contribute to the
treatment of lymphedema in the near future [65,66] .