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Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70 Page 3 of 13

on the medial and lateral side of the affected extremities as the lymphatics are more common in these
areas. Isosulfan blue (Lymphazurin; Covidien) is injected just distal to the incision site. The dye easily
gets absorbed into the lymphatic channels and facilitates easy visualisation of the lymphatic channels. In
advanced lymphoedema, the visualisation of the dye can be less due to weaker staining because of reduced
[10]
transport of the dye . Small subdermal venules less than 0.5 mm with no backflow are preferably chosen
for LVA since they have low intravascular pressure. Larger veins with backflow are associated with higher
intravascular pressure and obstruction of the anastomotic site.

Recently, magnetic resonance lymphangiography (MRL) has been added to the armamentarium to help
[11]
localise the lymphatic channels and venules for LVA . A mixture of paramagnetic contrast medium
containing gadobenate dimeglumine and lignocaine is injected subcutaneously/intradermally in the
webspaces of both feet and MRI is performed. MRL diagnoses lymphoedema, grades the lymphoedema
on the basis of the lymphatic drainage pattern and the delay of drainage, provides the number, diameter,
course, and depth from the skin of both affected lymphatic vessels and the nearest veins, the distance
between the lymphatics and the venules, and the location of the lymph nodes. Although the spatial
orientation of the lymphatics that MRL provides along with no radiation is a highlight, it has some
disadvantages in that it is costly, not freely available and time-consuming, and has occasional difficulty in
distinguishing the affected lymphatic vessel from the adjacent vein when there is dye contamination in the
venous system.

Once the appropriate lymphatic vessels and veins are identified, anastomosis is done between the lymphatic
channels and the veins. This can be a technical challenge as the veins and the lymphatics are very small.
Special instruments, sutures finer than 10-0 and high resolution microscopes with magnification of
20× to 30× are needed to perform this procedure. The anastomosis between lymphatics and veins are
most commonly done in an end-to-end manner. The lymphatic vessel is smaller and thinner and often
collapses, making it difficult to place the needle in the vessel. To increase the size of the lymphatic vessel,
[13]
[12]
Yamamoto et al. proposed clamping the proximal lymphatics and massaging distally. Narushima et al.
proposed using a 6-0 prolene suture as a stent within the lymphatic vessel to prevent suturing the backwall
during anastomosis. When the vein is much smaller than the lymphatic vessel, the end of the vein can
[14]
be sutured to the side of the lymphatic vessel in a side-to-end manner . There is also a concern that
the higher pressure in the vein can lead to obstruction of the anastomosis. Some proponents believe that
the most optimal orientation would be to anastomose the end of the vein to the side of the lymphatic
[15]
vessel, thus allowing the bidirectional flow of lymphatics to the veins . This could also be achieved by
[17]
[16]
anastomosing both the proximal and the distal cut ends of the lymphatics to veins . Chen et al. have
proposed the “octopus lymphovascular anastomosis technique”, where multiple small lymphatic channels
are anastomosed to a single vein. A 12-0 suture is placed transluminally on the vein and then through the
adventitia only on the lymphatic vessels which will cause intussusception of the lymphatic vessels into the
vein. After anastomosis, the patency and the flow direction can be assessed by using patent blue dye or ICG.

Postoperatively, Koshima advocates using an infusion of a vasodilator drug (prostaglandin E1) for 5 days
[10]
and then using an oral form for several weeks . As the incisions are only skin deep, the patient usually has
very little pain and can go home the same day. Bandages are applied until the wounds heal. Compression
stockings are used for 3 weeks after the operation and continued for at least 6 months after the procedure.

[18]
Scaglioni et al. reviewed 18 studies of LVA involving 939 patients and found that all studies showed
objective reduction in the circumference measurement. Subjective symptom relief was found in 50% to
100% of patients as well as reduction in the cellulitis episodes in all cases. Several studies also show a
[7]
striking reduction in the episodes of cellulitis post-surgery [19-21] . Results of LVA were noted by Chang et al.
to be better in the upper limb (96% symptomatic improvement) compared to the lower limb (57%