Introduction: Supermicrosurgical lymphaticovenular anastomosis (LVA) has become an accepted and effective treatment for lymphedema. Surgeons performing these procedures, however, have been perplexed in determining where to place their incisions to maximize the number of LVAs constructed. Here, we describe our guided approach to incision placement to increase the likelihood of creating a successful LVA at each incision.
Methods: Thirteen consecutive patients underwent LVA for treatment of secondary lymphedema. Incisions were placed using the guided approach in all the patients. Additional incisions were placed using the blind (anatomic) approach when the appropriate number of LVAs had not been achieved. In the guided approach, superficial lymphatics were mapped intraoperatively with indocyanine green (ICG) lymphography and superficial venules were mapped intraoperatively with near-infrared (NIR) vein visualization (Figure 2). Guided incisions were then placed where lymphatic vessels and superficial venules came into close contact or intersected (Figure 3). In the blind approach, incisions were placed along the anatomic course of the cephalic or greater saphenous vein (Figure 3). The number of LVAs constructed using each approach was compared. Fisher’s exact test was used for statistical analysis.
Results: A total of 99 LVAs were created through 80 incisions. Twelve of 31 (39% success) incisions using the blind approach and 42 of 49 (86% success) incisions using the guided approach allowed for successful LVA construction. The guided approach also resulted in more LVAs created per incision (1.7 vs. 0.5, P = 0.0001).
Conclusion: Use of a multimodality image guided approach significantly increases the probability of successful LVA creation at each incision as well as the total number of LVAs that are created within each incision.
Hawkes PJ, McNurlen M, Bowen M, Chen WF. Strategic Incision Placement to Facilitate Successful Supermicrosurgical LVA. International Microsurgery Journal 2018;1(3):5. DOI: 10.24983/scitemed.imj.2018.00049