Background Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis. Patients and Methods Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA. Results A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897–0.992, p < 0.001). The quality of patency was evaluated immediately after anastomosis, which assisted in deciding whether reanastomosis was needed. Conclusion Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status. Conception and design: A.H., H.Y., and J.P.H.; analysis and interpretation: A.H., H.Y., G.V., G.G., N.H., T.Y., and J.C.Y.; data collection: A.H., H.Y., and S.S.; statistical analysis: A.H., H.Y., G.V., and S.S.; writing the manuscript: A.H., H.Y., and J.P.H.; critical revision of the manuscript: A.H., H.Y., G.V., J.C.Y., and J.P.H.; final approval of the manuscript: A.H., H.Y., G.V., G.G., T.Y., J.C.Y., and J.P.H. This study was presented at the 2020 American Society of Reconstructive Microsurgery Annual Meeting. ^* These authors contributed equally to this work. Received: 24 May 2020 Accepted: 02 September 2020 Publication Date: 14 October 2020 (online) © 2020. Thieme. All rights reserved. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Background: For lymphedema patients who received a vascularized lymph node flap transfer (VLNT) as their primary treatment, what are the treatment options when they seek further improvement? With recent publications supporting the use of lymphaticovenous anastomosis (LVA) for treating severe lymphedema, we examined whether LVA could benefit post-VLNT patients seeking further improvement. Methods: This retrospective cohort study enrolled eight lymphedema patients with nine lymphedematous limbs (one patient suffered from bilateral lower limb lymphedema) who had received VLNT as their primary surgery. Patients with previous LVA, liposuction, excisional therapy, or incomplete data were excluded. LVA was performed on nine lower lymphedematous limbs. Demographic data and intraoperative findings were recorded. Preoperative and postoperative limb volumes were measured with magnetic resonance volumetry. The primary outcome was the limb volume measured 6 months post-LVA. Results: The median duration of lymphedema before LVA was 10.5 (4.9–15.3) years. The median waiting time between VLNT and LVA was 41.4 (22.3–97.9) months. The median volume gained in the lymphedematous limb was 3836 (2505–4584) milliliters (mL). The median post-LVA follow-up period was 18 (6–30) months. Significant 6-month and 1-year post-LVA percentage volume reductions were found compared to pre-LVA volume (both p < 0.001). Conclusion: Based on the results from this study, the authors recommend the use of LVA as a secondary procedure for post-VLNT patients seeking further improvement.

Background Currently, microsurgeons are in the era of supermicrosurgery and perforator flap reconstruction. As these reconstructions frequently utilize vessels that are smaller than a single millimeter, understanding of location of lymphatic vessels and perforator anatomy preoperatively is essential. To change with the times, the role of ultrasound has changed from just an adjunct to primary imaging of the choice in reconstructive supermicrosurgery. Recently, a novel ultrasonographic technique involving the use of ultra-high frequency ultrasound (UHFUS) frequencies has entered the scene, and appears a promising tool in surgical planning. Methods The literatures on the applications of UHFUS in reconstructive supermicrosurgery were retrieved and reviewed from more than 60 literatures have been published on the surgical applications of UHFUS. Results Nine studies were retrieved from the literature on the applications of UHFUS in reconstructive supermicrosurgery. The articles report both application for lymphatic surgery and perforator flaps. Conclusion UHFUS application involves an increasing number of reconstructive supermicrosurgery field. UHFUS is a valuable and powerful tool for any reconstructive surgeons who are interested in performing supermicrosurgery.

The management of lymphatic malformations (LMs) is challenging, particularly for large and complex lesions involving anatomical structures in the adjacent tissue. While lymphovenous anastomosis (LVA) has been reported as an effective treatment for lymphedema, it has hardly been described as a treatment for LM. Virtual reality has the ability to visualize human structures in three dimensions and can be used for the preoperative planning of complex cases. Here, we describe the first case of the management of an LM by LVA preoperatively planned with virtual reality. A young woman presented with an LM previously treated by gross excision. Following persistent complaints of swelling, a minimally invasive microsurgical intervention was planned. The results of the single photon emission tomography with computed tomography (SPECT-CT) and lymphoscintigraphy were analyzed using a virtual reality program, and a 3D patient-specific model was constructed. Based on the combined findings of this 3D model and lymphography with a fluorescent marker, a precise skin incision could be determined and one lymph vessel was anastomosed to a nearby vein. The swelling of the thigh reduced and the discomfort disappeared. Although more reports are needed to confirm its efficacy, LVA planned with virtual reality constructed images appears to be a valuable treatment option for complex lesions, including LMs.

Background: The modern concept of lymphatic transfer includes vascularised lymph node transfer (VLNT), lymphatic vessels transfer (lymph interpositional flap transfer, LIFT) and lymphatic system transfer (vascularised lymph nodes and afferent lymphatics, LYST). The aim of this paper was to report our experience with different types of lymphatic transfer. Patients and Method: From June 2016 to June 2020, 30 consecutive patients affected by extremity lymphedema and 15 patients affected by post-traumatic lower extremity soft tissue defects, underwent lymphatic transfer (VLNT, LYST or LIFT). All cases were preoperatively evaluated by both high frequency and ultra-high frequency ultrasound. Flap features were recorded, as well as qualitative and quantitative outcomes at 1 year postoperative. Results: The mean postoperative lymphedema index reduction was 7.2 ± 5.7 for upper extremity and 20.7 ± 7.1 for lower extremity. No dismission of compression garments occurred, 12 patients (26%) referred more stable results of physical treatment and 1 case showed a 1-class compression reduction. All the LIFTs aimed as preventive did not develop post-traumatic lymphedema. In all cases of distal placement of VLNT and/or LYST, patients were dissatisfied with the aesthetic appearance of reconstruction, while no donor site scar disappointment was referred. Conclusion: When LVA is not feasible, LTT may represent a valid treatment option. This report was aimed at comprehensively describing and assessing how different lymphatic tissue transfer modalities may fulfil the different reconstructive needs of lymphedema patients.

Background/Objectives: Recent advancements in breast cancer treatment have led to increased survival rates, prompting a shift towards addressing breast cancer-related lymphedema (BCRL). Despite the evolving role of lymphatic surgery in breast reconstruction, there is limited literature evaluating the current role of lymphatic surgery in breast reconstruction. This review aims to evaluate the state of lymphatic surgery in breast reconstruction, analyzing surgical techniques and proposing a multi-institutional algorithmic approach. Methods: Through a search and screening of literature, data regarding the study type, type of operation (bypass, pLVB/ILR/LYMPHA, VLNT, or a combination of treatments), and clinical outcomes were collected. Results: The systematic review included 184 studies. Overall, the number of publications on lymphatic surgery increased from 4.4 per year (2010–2016) to 21.1 per year since 2017. The most published procedure was vascularized lymph node transfer (34.6%), followed by preventive lymphatic surgery (31.4%), therapeutic lymphovenous bypass (23.3%), and combined breast and lymphatic reconstruction (10.7%). While VLNT was the most published procedure, preventive surgery has been the most published topic since 2020, with 11.7 articles per year since. Similarly, there has been an increase in studies on combined lymphatic surgery and breast reconstruction in the last five years, with 16 articles published. Conclusions: The role of lymphatic surgery in breast cancer patients is evolving, with an increasing emphasis on preventive procedures and combined reconstructive approaches. However, our study shows that the current literature is predominantly based on lower-level evidence, highlighting the need for more randomized controlled trials to establish stronger clinical recommendations.