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Fig. 50.6 LVA step 1. Skin is incised carefully with a surgical scalpel

T. Yamamoto and N. Yamamoto

Fig. 50.8 LVA step 3. The supercial fascia is widely exposed, and carefully incised with a needle-tip electric cautery

Fig. 50.7 LVA step 2. A vein is dissected with inter-lobular dissection method in the supercial fat layer above the supercial fascia

• Step 2. Dissection of Recipient Vein [Fig. 50.7]. Using a needle-tip electric cautery with power level set at 5–7, the supercial fat layer is dissected to seek for a recipient vein. Dissection should go between the fat lobules; inter- lobular dissection. A vein is dissected and cut as distally as possible to include many valves inside; important to prevent venous reux which is a major risk factor of LVA site thrombosis.

• Step 3. Exposure and Careful Incision of the Supercial Fascia [Fig. 50.8]. Inter-lobular dissection continues deeply to the supercial fascia. The supercial fascia should be explored as widely as possible in a surgical eld. The supercial fascia is very carefully incised with a needle-tip electric cautery; lymph vessels, if present, lie just below the supercial fascia.

Fig. 50.9 LVA step 4. A lymph vessel is dissected with inter-lobular dissection method in the deep fat layer below the supercial fascia

• Step 4. Dissection of Lymph Vessel [Fig. 50.9]. Deep fat layer is dissected inter-lobularly with a dissector or a netip mosquito to seek for lymph vessels. Every inter- lobular space should be explored throughout the eld. A lymph vessel, when found, is marked with 3–0 nylon thread not to lose it.

• Step 5. Supermicrosurgical Anastomosis in an Intima- to- Intima Coaptation [Fig. 50.10]. A lymph vessel is anastomosed to a vein in an intima-to-intima coaptation manner using 11–0 (65 μm needle), 12–0 (50μm needle), or 12–0s (30μm needle) supermicrosutures; 11–0 for 0.4–1.0 mm vessel, 12–0 for 0.2–

0.6 mm vessel, and 12–0 s for 0.1–0.3 mm vessel. Usually, six stiches are put for one end-to-end anastomosis.

50 Lymphatic Supermicrosurgery

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Fig. 50.10 LVA step 5. Supermicrosurgical anastomosis is done in an intima-to-intima coaptation manner

Fig. 50.11 LVA step 6. Anastomosis is evaluated regarding patency and leakage. Intraoperative ICG lymphography (right)

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• Step 6. Evaluation of Anastomosis Patency [Fig. 50.11]. Patency is evaluated with venous expansion lled with translucent lymph. Intraoperative ICG lymphography is useful to rule out minor leakage.

• Step 7. Protection of the Anastomosis Site and Vessels [Fig. 50.12]. The anastomosis site and vessels are covered with the surrounding fat tissue to place them as deep as possible.

• Step 8. Careful Skin Closure [Fig. 50.13]. Skin is closed carefully under an operating microscope, not to affect the anastomosis site and vessels.

Fig. 50.12 LVA step 7. The anastomosis site and vessels are covered with the surrounding fat tissue

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Fig. 50.13 LVA step 8. Skin is closed carefully not to affect the anastomosis site and vessels

50.5 Supermicrosurgical LLA forLymphorrhea/-cyst: AStep-by-Step Guide

• Step 1. Exploration Inside a Cyst [Fig. 50.14]. Usually,

there is a cyst formation in the lesion, which is opened up to explore inside. If the history is long, capsulectomy should be done. As in LVA, whole procedures are done under an operating microscope.

• Step 2. Identication of Ruptured Lymph Vessel [Fig.

50.15]. Careful observation is conducted to seek for rup-

tured lymph vessels under intraoperative ICG lymphography navigation; if ICG is not available, dye injection is helpful. The ruptured lymph vessel, when found, is dissected distally for subsequent anastomosis.

• Step 3. Dissection of Recipient Vessel [Fig. 50.16].

Nearby intact lymph vessel is searched under intraoperative ICG lymphography. When found close enough to the ruptured lymph vessel, the recipient lymph vessel is dissected proximally and distally for subsequent end-to-side LLA. If there is no recipient lymph vessel suitable for LLA, a vein is searched for LVA.If there is no recipient lymph or vein, the ruptured lymph vessel is just supermicrosurgically ligated for secure closure.

• Step 4. Supermicrosurgical Anastomosis in an Intima-

to- Intima Coaptation [Fig. 50.17]. Lymphotomy is per- formed on the recipient lymph vessel, and end-to-side LLA is performed; the ruptured lymph vessel stump is anastomosed to a side of the recipient lymph vessel to preserve native lymph ow in the recipient.

• Step 5. Evaluation of Patency and Leakage [Fig.

50.18]. Anastomosis site is evaluated under intraoperative

ICG lymphography navigation; there should be good ow and no leakage.

• Step 6. Placement of Drain and Skin Closure. Wound is

closed layer by layer, after placement of a drain.

T. Yamamoto and N. Yamamoto

Fig. 50.14 LLA step 1. A lymphocyst is opened to seek for ruptured lymph vessels. Intraoperative ICG lymphography navigation (lower right)

Fig. 50.15 LLA step 2. A ruptured lymph vessel (arrows) is found in the lesion. Intraoperative ICG lymphography navigation (upper left)

50 Lymphatic Supermicrosurgery

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Fig. 50.16 LLA step 3. An intact lymph vessel (arrowhead), located close to the ruptured lymph vessel (arrow), is dissected under intraoperative ICG lymphography navigation

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50.6 Pearls andPitfalls

Dynamic ICG lymphography is important for evaluation of lymphatic disease before lymphatic supermicrosurgery. LVA is best indicated for ICG stage II–IV cases. Slightly sclerotic “s1” lymph vessel should be used for LVA. “Overlapping region,” revealed by dynamic ICG lymphography, is best for LVA. Intact lymph vessel should be preserved; LVA should not be performed in a non-edematous region where ICG lymphography shows linear pattern only. Bloodless inter-lobular dissection is a key to successful supermicrosurgery; all important structures, blood vessel, nerve, and lymph vessel exist between the fat lobules. Once a eld is stained or contaminated with blood, it is impossible to securely dissect translucent lymph vessels from the surrounding yellow fat tissues. Intima-to-intima coaptation anastomosis is a basis of supermicrosurgery; a supermicrosurgeon has to be used to 11–0, 12–0, and 12–0s supermicro-sutures.

Fig. 50.17 LLA step 4. End-to-side LLA is performed using 12–0 supermicro-suture

Fig. 50.18 LLA step 5. Anastomosis site is evaluated regarding patency and leakage under intraoperative ICG lymphography navigation. Conventional microsurgical view (lower left)

50.7 Selected Readings

• Yamamoto T, Narushima M, Doi K, Oshima A, Ogata F, Mihara M, Koshima I, Mundinger GS. Characteristic indocyanine green lymphography ndings in lower extremity lymphedema: the generation of a novel lymphedema severity staging system using dermal backow patterns. Plast Reconstr Surg. 2011;127(5):1979–86.

• The rst description of characteristic ICG lymphography

ndings and pathophysiological severity staging system for lower extremity lymphedema based on ICG lymphography ndings. Linear, Splash, Stardust, and Diffuse patterns are introduced.

• Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I.Factors associated with lymphosclerosis: an analysis on 962 lymphatic vessels. Plast Reconstr Surg 2017;140(4):734–41.

• Severity grade for lymphosclerosis, consisting of “s0,”

“s1,” “s2,” and “s3”, is described. Comprehensive analysis with multivariate analysis reveals independent factors associated with lymphosclerosis.

• Yamamoto T, Narushima M, Yoshimatsu H, Yamamoto N, Kikuchi K, Todokoro T, Iida T, Koshima I.Dynamic indo-

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T. Yamamoto and N. Yamamoto

cyanine green lymphography for breast cancer-related arm lymphedema. Ann Plast Surg. 2014;73(6):706–9.

• The rst description of dynamic ICG lymphography.

Protocol of dynamic ICG lymphography is reported, and lymph pump function, measured with ICG velocity, is evaluated according to ICG lymphography stage.

• The rst description of ICG lymphography-based patho-

physiological severity staging system for upper extremity lymphedema. Characteristic ICG lymphography ndings in upper extremity lymphedema are introduced, and evaluated according to clinical stage.

• Yamamoto T, Narushima M, Yoshimatsu H, Seki Y, Yamamoto N, Oka A, Hara H, Koshima I. Minimally invasive lymphatic supermicrosurgery (MILS): indocyanine green lymphography-guided simultaneous multi-site lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014;72(1):67–70.

• Application of intraoperative ICG lymphography to fur-

ther minimize invasiveness of LVA surgery. LVA can be performed via a millimeter skin incision with appropriate ICG lymphography mapping.

• Yamamoto T, Yamamoto N, Azuma S, Yoshimatsu H, Seki Y, Narushima M, Koshima I.Near-infrared illumination system-integrated microscope for supermicrosurgical lymphaticovenular anastomosis. Microsurgery 2014;34(1):23–7.

• Application of intraoperative ICG lymphography to navi-

gate LVA surgery. Lymph vessels can be easily found even in DB region under intraoperative ICG lymphography navigation.

• Yamamoto T, Yoshimatsu H, Koshima I.Navigation lymphatic supermicrosurgery for iatrogenic lymphorrhea:

supermicrosurgical lymphaticolymphatic anastomosis and lymphaticovenular anastomosis under indocyanine green lymphography navigation. J Plast Reconstr Aesthet Surg. 2014;67(11):1573–9.

• First description of LLA for intractable lymphorrhea

cases. Surgical strategy for intractable lymphorrhea cases are described, including end-to-side LLA and conventional LVA under intraoperative ICG lymphography navigation.

• Yamamoto T, Yamamoto N, Yamashita M, Furuya M, Hayashi A, Koshima I.Efferent lymphatic vessel anastomosis (ELVA): supermicrosurgical efferent lymphatic vessel-to-venous anastomosis for the prophylactic treatment of subclinical lymphedema. Ann Plast Surg. 2016;76(4):424–7.

• First description of efferent lymphatic vessel anastomosis

for prophylactic treatment of subclinical lymphedema. Ideal way of secondary prophylaxis is described.

• Yamamoto T, Yoshimatsu H, Yamamoto N. Complete lymph ow reconstruction: a free vascularized lymph node true perforator ap transfer with efferent lymphaticolymphatic anastomosis. J Plast Reconstr Aesthet Surg. 2016;69(9):1227–33.

• A special case of LLA combined with lymph node transfer,

showing the rst evidence of lymph drainage after lymph node transfer. The efferent lymph vessel of the transferred lymph node is anastomosed to contralateral iliac lymph vessel, to achieve complete lymph ow reconstruction.

• Yamamoto T, Narushima M, Kikuchi K, Yoshimatsu H, Todokoro T, Mihara M, Koshima I.Lambda-shaped anastomosis with intravascular stenting method for safe and effective lymphaticovenular anastomosis. Plast Reconstr Surg. 2011;127(5):1987–92.

• Introduction of int ravascular stenting method for lambda-

shaped LVA.Bidirectional bypass LVA can be safely performed even by a beginner supermicrosurgeon with modied intravascular stenting method.

Part IV

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Appendix

Cadaveric Anatomy: Microvascular Flaps Dissection

GeorgiosPatanis, DajiangSong, andYoumaoZheng

Fig. 51.1 Fasciocutaneous ap perforators dissection

G. Patanis (*) Department of Plastic Surgery, Emergency Care and Trauma Division (ECAT), The Royal London Hospital, Barts Health NHS Trust & University College Hospital London (UCLH), London, UK e-mail: georgios.patanis@nhs.net

D. Song Department of Oncology Plastic Surgery, Hunan Cancer Hospital and The Afliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China

Y. Zheng Department of Hand and Foot Surgery, Taizhou Hospital, Wenzhou Medical University and The Third Afliated Hospital of Southern Medical University, Taizhou, Zhejiang Province, China

Fig. 51.2 Chapter 14: LD muscle ap

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