Background Microsurgical vascularized lymph node transfer (VLNT) and supermicrosurgical lymphaticovenular anastomosis (LVA) are increasingly performed to treat lymphedema. The surgical outcome is commonly assessed by volume-based measurement (VBM), a method that is not consistently reliable. We describe indocyanine green (ICG) lymphography as an alternative postoperative tracking modality after lymphatic reconstruction with VLNT and LVA. Methods VLNT and LVA were performed in patients with therapy-refractory lymphedema. Patients were evaluated qualitatively by clinical assessment, quantitatively with VBM, and lymphographically using ICG lymphography. The evaluation was performed preoperatively, and at 3, 6, and 12-month postoperatively. Results Overall, 21 patients underwent lymphatic reconstruction with either VLNT or LVA. All reported prompt and durable relief of symptoms during the study period. All experienced disease regression based on the Campisi criteria. Out of the 21 patients, 20 (95%) demonstrated lymphographic down staging of disease severity. Out of the 21 patients, 3 (14%) developed a paradoxical increase in limb volume based on VBM despite clinical improvement. Conclusions ICG lymphography correlated highly with patient self-assessment and clinical examination, and is an effective postoperative tracking modality after lymphatic reconstruction. Each person listed as an author has participated in the study to a significant extent.

Background Supermicrosurgical lymphaticovenular anastomosis (LVA) is a promising treatment modality for lymphedema. However, its practice is restricted by the surgeon/equipment-related factors, and its effectiveness limited by technical constraints. We conducted a pilot study to evaluate the feasibility of a modified “octopus” LVA technique in addressing the above problems. Method Nine consecutive lymphedema patients underwent LVA procedure using the “octopus” technique. Six had the upper extremity disease; three had the lower extremity disease. Except for one patient having primary lower extremity lymphedema, all had secondary disease related to cancer treatment. Disease severity ranged from Campisi stage Ib to IV. Qualitative and quantitative assessments were performed preoperatively, at 1, 3, and 6 months. Results A total of 130 lymphaticovenular drainage pathways were created in 39 “octopus” LVAs. All patients experienced prompt relief of lymphedema symptoms during the 1st postoperative week and continued to improve during the study period. None had postoperative complications. All had disease regression as demonstrated by statistically significant decrease in limb measurements (p = 0.0003) and severity down-staging. The modified technique was found to be easier than the standard supermicrosurgical technique and could be performed using a standard surgical microscope. Conclusion The “octopus” technique is a viable, effective technical alternative to the standard LVA technique. It may greatly simplify this technically challenging procedure. This article represents an original contribution and has not been previously published.