Page 83 - Read Online

Page 6 of 12 Pandey et al. Plast Aesthet Res 2021;8:47 https://dx.doi.org/10.20517/2347-9264.2021.61

Figure 4. A variety of anastomotic configurations (named in a lymphatic-to-vein convention) are available to maximize anterograde
drainage. (A) Single end-to-end anastomosis, (B) end-to-end anastomosis of two lymphatics to two venous branches, (C) end-to-side
anastomosis, (D) depicts multiple small-caliber, fibrotic (non-translucent) lymphatic vessels and a single, large-caliber vein, for which
(E) an invaginating “octopus” technique is most appropriate. L: Lymphatic; V: venule.

[64]
before declaring failure . It can be promoted by massaging distal to incision. Leakproof anastomosis is
essential to allow lymphatic pressure to build up and overcome the venous pressure . If the microscope is
[65]
[65]
equipped with an ICG module, patency can be confirmed by observing ICG flow into the veins . If
backflow of blood into the lymphatic vessel is observed, venous pressure has exceeded lymphatic pressure,
and the anastomosis is at risk of thrombosis.

[31]
Controversy exists regarding the optimal number of LVAs . Theoretically, a few high-quality anastomoses
(antegrade flow anticipated) should suffice, but reality often necessitates a quantity-over-quality approach.
In keeping with this, the senior author (Chen WF) has demonstrated considerable clinical success when
using suboptimal vessels by creating 8 to 15 LVAs per case [48,54,64] . The following are used as the procedure
endpoints: (1) six hours of operative time; for experienced microsurgeons, continuing beyond this duration
typically yields diminishing returns; (2) three consecutive negative incisions (i.e., no suitable lymphatics
found when proceeding in a distal-to-proximal fashion); or (3) substantial drainage through LVAs causing
visible limb decompression on the table .
[54]

Frequently refreshing supermicrosurgical skills on practice models can shorten the learning curve for LVA
in budding lymphedema surgeons .
[66]