Page 64 - Read Online

Seki et al. Plast Aesthet Res 2021;8:44 https://dx.doi.org/10.20517/2347-9264.2021.74 Page 7 of 11

In these situations, microsurgeons tend to misunderstand that there are no lymphatic vessels at the incision
point. However, the truth is that fragile lymphatic vessels are at the site of incision and all lymphatic vessels
are ruptured within fibrotic tissues. Even in this situation, careful detection of the ruptured stump of the
lymphatic vessels could result in successful LVA by refreshing the stump of the lymphatic vessels after re-
dissection. The subcutaneous veins are also difficult to dissect in these fibrotic tissues. Microsurgeons
should not regret finding lymphatic vessels from fibrotic tissues in severe lymphedema patients.

Techniques in LVA STEP 3: anastomosis
In anastomosing the lymphatic vessel and the subcutaneous vein, the one-hand suture technique is applied.
Before the suture, one side tip of the left-hand forceps is used to dilatate the vessel’s lumen. If all the vessels
are less than 0.20 mm in diameter with severe sclerosis, or if the lymphatic vessel’s intima seems to be easily
peeled off by sclerosis, the tip of the right-hand needle (11-0, 12-0, or 12-0s) is utilized as a dilator, which is
inserted into the intima.

In progressive lymphedema, creating intima-to-intima anastomosis between the sclerosed lymphatic vessel
and the subcutaneous vein is challenging because sclerotic changes of lymphatic vessel make the lumen
narrow and fragile. Inaccuracy of the anastomosis in LVA sometimes results in early- or mid-postoperative
occlusion. It should be noted that inaccurate procedures in LVA could result in not only early- but also
mid-postoperative occlusion because venous thrombosis of LVA is considered to occur less in early phase
and more in later phase compared to arterial or venous anastomosis.

In addition, to keep long-term steady flow at LVA, sequential structural disturbance between the lymphatic
vessel and the subcutaneous vein should be avoided. At the time of LVA creation, lymphatic vessels are
dilatated because of lymphatic fluid excess in the affected limb. However, lymphatic dynamics can change
dynamically after LVA: lymphatic flow in LVA is decreasing according to lymphedema improvement in
med- postoperative course. The structural disturbance becomes remarkable between lymphatic vessels and
subcutaneous veins because lymphatic vessels become smaller over time when the subcutaneous veins do
not change in size. Therefore, the relatively smaller subcutaneous vein should be selected for LVA when the
lymphatic vessels are abnormally dilatated.

To eliminate early- and mid-postoperative occlusions, improving accuracy of intima-to-intima
anastomosing of LVA is important. We previously reported several technical tips in supermicrosurgery,
[23]
including spear technique to handle small needle in any direction and advanced techniques using one-
hand suture technique, which facilitate LVA.

Spear technique
The spear technique is a useful supermicrosurgical suture technique to anastomose small vessels, in which
the 11-0, 12-0, or 12-0s needle can be utilized freely from any direction. Proper combination of the angle
and the holding part of the needle make microsurgeons’ hand sensation possible to feel the lumen of the
small vessels and/or lymphatic flow in spear type needle holding. Performance of the LVA with spear
technique is described in Supplementary Video 1-3.

Supermicrosurgical LVA style 1: step-by-step suture technique [Supplementary Video 1]
The first suture is performed using the one-hand suture technique. In this LVA style, the following suture is
just put next to the last one. With this technique, the microsurgeon can make each suture by checking the
lumen of the vessels until the second last suture. In addition, the microsurgeon can check the lumen of the
vessels by inserting the one side tip of the forceps if needed. LVA is completed without concerns of picking