Selection of anastomosis type for lymphaticovenular anastomosis

Abstract

We read with great interest the article entitled “pshaped lymphaticovenular anastomosis for head and neck lymphoedema: a preliminary study” by Ayestaray et al. (J Plast Reconstr Aesthet Surg. 2012 Oct 4 [Epub ahead of print]). Their work is of clinical significance in that they reported case series of head and neck lymphoedema successfully treated with supermicrosurgical lymphaticovenular anastomosis (LVA), because head and neck lymphoedema treatment is challenging due to difficulty of compression therapy. I would like to discuss how to select anastomosis type of LVA, and want to make some comments on this matter. An operator of LVA should select an appropriate anastomosis type according to vessels available in a surgical field. There are 4 basic anastomosis types of LVA; end-to-end (EeE), end-to-side (EeS), side-to-end (SeE), and side-toside (SeS). Regarding selection of anastomosis type in LVA surgery, we lymphatic supermicrosurgeon should take 3 points into consideration; venous backflow rate, technical difficulty, and bypass efficacy. As we reported previously, venous backflow rate is high in EeS anastomosis compared with EeE or SeE anastomosis, EeE anastomosis is technically easiest, and SeE and SeS anastomosis can bypass lymph fluid more efficiently compared with EeE and EeS anastomosis. Therefore, I usually perform LVA in a SeE manner, because SeE anastomosis carries a low risk of venous backflow and can bypass both normoand retrograde lymph flows via one anastomosis. When a lymphatic vessel is too sclerotic to create a side wall for SeE anastomosis, we perform EeE anastomosis or l-shaped (EeE and EeS) anastomosis, because EeE anastomosis is technically easy and carries a low risk of venous backflow. When a vein