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Page 4 of 12 Pandey et al. Plast Aesthet Res 2021;8:47 https://dx.doi.org/10.20517/2347-9264.2021.61

Figure 1. A representative case of TDAP-based VLVT for unilateral upper extremity lymphedema. (A) TDAP flap was harvested
superficially to the superficial fascia for inset into the distal volar forearm. (B) Preoperative image showing significant swelling of the
right upper extremity. (C) Measurements 3 months postoperatively show a significant reduction in the girth of the right upper
extremity. The thin profile of VLVT flaps minimizes flap bulk; thus, contour deformity of the recipient site is avoided. TDAP:
Thoracodorsal artery perforator; VLVT: vascularized lymph vessel transplant.

Anastomosis
The overall goal of LVA is to create lymphatic-to-venous anterograde flow in as many drainage pathways as
possible [48,55-57] . Scenarios of vessel number mismatch, unfavorable pressure gradients, vessel size mismatch,
and awkward vessel positioning can be encountered in different combinations. A variety of anastomotic
configurations have been developed to overcome such obstacles, named in a lymph-to-vein convention [57-60] ,
as shown in Figure 4.

When lymphatic pressure exceeds venous pressure, all configurations should work; end-to-end will often be
chosen as it is the most technically straightforward. However, when the pressure gradient is unfavorable,
side-to-side or end-to-side is chosen to take advantage of Bernoulli’s principle . Side-to-side is the more
[54]
technically challenging and should be performed only if the involved vessels are 0.4 mm or more in
diameter. If end-to-end configuration is the only option available due to size limitations, immediate
[61]
postoperative compression can alter the pressure gradient to facilitate anterograde flow .

12-0 nylon on a 50-um needle is generally preferred for anastomosis, but 11-0 nylon can be used for vessels
0.5 mm or larger in diameter. As the vessels are too small for supermicrosurgical forceps tips to insert into
the lumen, the needle tip can be used to evert the vessel edge against the side of the forceps with or
[48]
without the use of a 7-0 monofilament nylon suture acting as an intravascular stent [60,62,63] .