Morel-Lavallee Lesions lead to disruption of lymphatic anatomy that require early identification and may necessitate lymphatic reconstruction. We present the case of a 59-year-old male with lower extremity lymphedema resulting after a severe Morel-Lavallee lesion and treated using lymphovenous anastomoses. He was initially managed with multiple aspirations followed by repeat incision and drainage. At 10 months following his injury, he continued to have swelling of his upper thigh and developed a large festoon medially, with lower leg pitting edema. He was diagnosed with lymphedema via lymphoscintigraphy. His superficial lymphatic anatomy was visualized using indocyanine green (ICG) lymphography and showed diffuse dermal backflow across his thigh, with signs of altered lymphatic anatomy distally. We preformed two lymphovenous anastomoses at the level of his mid-thigh to bypass the lymphatic disruption and restore drainage to his lower leg. After rerouting lymphatic flow from the lower extremity, the patient had overall improvement of his symptoms and reduced swelling with continued therapy. At 5 months postoperatively, his volumetric lower extremity measurements showed a decrease by 314 mL and he began walking again in 20-minute intervals. Lymphedema may be an important consideration following severe Morel-Lavallee lesions. Using modern diagnostic and supermicrosurgical techniques, plastic surgeons can help treat this long-term morbidity.

Persistent lymphocele of the groin is a complication of groin surgery that can severely impact the quality of life. The restoration of the interrupted lymphatic pathway is considered by many authors the ideal treatment to prevent a recurrence. However, multiple aspiration procedures and surgical revisions can compromise the availability of local veins needed for a lymphovenular bypass surgery. In addition, surgical debridement of a long-standing lymphocele can generate extensive dead space and contour deformity. A flap delivering additional venules for trans-flap lymphovenular anastomoses (LVAs) can overcome both problems by providing soft tissue and competent veins harvested outside the zone of injury. A successful case of severe groin lymphocele treated with trans-flap LVAs from an abdominal-based flap is presented. The patient was referred to us for a recurrent lymphocele developed in the right groin after lipoma excision that persisted despite multiple surgical attempts. After the identification of patent and draining inguinal lymphatic vessels, a pinch test was used to design a mini-abdominoplasty superficial inferior epigastric artery flap. The superficial veins of the cranial incision were identified and anastomosed to the lymphatic vessels after the pedicled flap harvested and insetted in the groin. The early restoration of lymphatic drainage and the optimal aesthetic outcome supports the combined approach offered by trans-flap LVAs as a valuable therapeutic option for severe and persistent lymphocele.

Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.

UNASSIGNED: In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid.
UNASSIGNED: We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions.
UNASSIGNED: Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported.
UNASSIGNED: The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature.

BACKGROUND: Exact quantification of volumetric changes of the extremities is difficult and often error-prone. The aim of this study was to establish a standardized method based on 3-dimensional (3D) scans. Furthermore, this study tests the method in terms of reproducibility and evaluates volume changes after surgical therapy in patients suffering from lymphedema on the lower extremity.
METHODS: 3D scans of the lower limb were performed with a mobile 3D scanner; \"repeatability\" and \"interobserver reliability\" of digital volumetry were tested. Furthermore, the method was applied on 31 patients suffering from chronic lymphedema.
RESULTS: Calculations of repeatability of the volume based on 20 3D scans of the same lower leg showed a mean volume of 2.488 ± 0.011 liters (range: 2.470-2.510). The mean volume of the different examiners did not differ significantly (F(2,18) = 1.579, P = 0.233). The paired t-test showed a significant mean volume decrease of 375 mL (95% confidence interval = 245/505 mL) between pretreatment and post-treatment (t (30) = 5.892, P < 0.001).
CONCLUSIONS: 3D volumetry is a noninvasive, easy, and quick method to assess volume changes of the lower leg. Other than the low costs, it is reproducible and precise and therefore ideal for evolution of therapy in lymphedema.

UNASSIGNED: Breast cancer-related lymphedema impacts 30% to 47% of women who undergo axillary lymph node dissection (ALND). Studies evaluating the effectiveness of prophylactic lymphovenous bypass (LVB) at the time of ALND have had small patient populations and/or short follow-up. The aim of this study is to quantitatively and qualitatively evaluate prophylactic LVB in patients with breast cancer.
UNASSIGNED: A retrospective review of patients who underwent ALND from 2018 to 2022 was performed. Patients were divided into cohorts based on whether they underwent prophylactic LVB at the time of ALND. Primary outcomes included 30-day complications and lymphedema. Lymphedema was quantitatively evaluated by bioimpedance analysis, with L-dex scores >7.1 indicating lymphedema.
UNASSIGNED: One-hundred five patients were identified. Sixty-four patients (61.0%) underwent ALND and 41 patients (39.0%) underwent ALND+LVB. Postoperative complications were similar between the cohorts. At a median follow-up of 13.3 months, lymphedema occurred significantly higher in the ALND only group compared with ALND+LVB group (50.0% vs 12.2%; P < 0.001). ALND without LVB was an independent risk factor for lymphedema development (odds ratio, 4.82; P = 0.003).
UNASSIGNED: Prophylactic LVB decreases lymphedema and is not associated with increased postoperative complications. A multidisciplinary team approach is imperative to decrease lymphedema development in this patient population.

Primary lymphedema is a heterogeneous group of conditions encompassing all lymphatic anomalies that result in lymphatic swelling. Primary lymphedema can be difficult to diagnose, and diagnosis is often delayed. As opposed to secondary lymphedema, primary lymphedema has an unpredictable disease course, often progressing more slowly. Primary lymphedema can be associated with various genetic syndromes or can be idiopathic. Diagnosis is often clinical, although imaging can be a helpful adjunct. The literature on treating primary lymphedema is limited, and treatment algorithms are largely based on practice patterns for secondary lymphedema. The mainstay of treatment focuses on complete decongestive therapy, including manual lymphatic drainage and compression therapy. For those who fail conservative treatment, surgical treatment can be an option. Microsurgical techniques have shown promise in primary lymphedema, with both lymphovenous bypass and vascularized lymph node transfers demonstrating improved clinical outcomes in a few studies.

UNASSIGNED: Lymphedema is a common complication of lymph node surgery; however, evidence on diagnosing, monitoring, and treating the condition is sparse. This meta-analysis evaluates the outcomes of common surgical treatments of lymphedema and provides suggestions for future research directions.
UNASSIGNED: A review of PubMed and Embase was performed according to Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. All English-language studies published through June 1, 2020, were included. We excluded nonsurgical interventions, literature reviews, letters, commentaries, nonhuman or cadaver studies, and studies with inadequate sample size (N < 20).
UNASSIGNED: A total of 583 cases from 15 studies in patients with lymphedema met our inclusion criteria for our 1-arm meta-analysis: 387 upper extremity treatments and 196 lower extremity treatments. The volume reduction rates of lymphedema for upper extremity and lower extremity treatments were 38.0% [95% confidence interval (CI), 25.9%-50.2%] and 49.5% (95% CI, 32.6%-66.3%), respectively. The most common postoperative complications were cellulitis, reported in 4.5% of patients (95% CI, 0.9%-10.6%), and seromas, reported in 4.6% (95% CI, 0%-17.8%) of patients. Average quality of life measures across all studies improved by 52.2% (95% CI, 25.1%-79.2%) for patients who underwent upper extremity treatment.
UNASSIGNED: Surgical management of lymphedema shows great promise. Our data suggest that adopting a standardized system of limb measurement and disease staging can increase effectiveness of treatment outcomes.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

OBJECTIVE: Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates.
METHODS: Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed.
RESULTS: A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9 months (range 6-63 months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified.
CONCLUSIONS: Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.