American Association of Plastic Surgeons

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Overcoming The "No Linear, No LVA" Paradigm: Feasibility Of Lymphaticovenular Anastomosis Without Indocyanine Green Linear Patterns
David Chon Fok Cheong, M.D., Shih Lun Lo, M.D., Melis Salman, M.D., Berk B. Ozmen, M.D., Wei F. Chen, M.D..
Cleveland Clinic, Cleveland, OH, USA.

Purpose The presence of a "linear" indocyanine green lymphography (ICGL) pattern is often considered essential for successful lymphaticovenular anastomosis (LVA), with its absence viewed as a contraindication. However, research suggests that missing lymphographic patterns do not necessarily indicate the anatomical absence of lymph vessels. Given the anatomical parallel between the superficial lymphatic and venous systems, we tested a "follow-the-vein" (FV) approach for LVA and compared its effectiveness to the conventional "follow-the-linear" (FL) method.
Methods Patients who underwent LVA from January 2020 to December 2023 at Cleveland Clinic were included, with those showing a "linear" ICGL pattern in the FL group and those without it in the FV group. Surgical feasibility and outcomes were compared based on patient-reported outcomes (PRO), surgical times, and ICGL results.
Results Among 98 patients (70 FL, 28 FV), demographics were comparable. The FL group had 4.56 incisions and 7.2 anastomoses per surgery, with a 96.2% success rate in locating lymphatic channels. The FV group had 5.1 incisions and 8.7 anastomoses, with a 93% success rate of locating the lymphatic channels. Surgical times were similar across groups. Both approaches reported high satisfaction, significant reductions in edema, and improvements in function, pain, and exercise tolerance. PRO improvements were noted in 97.1% of FL and 89.3% of FV cases, with ICGL improvements in 94.3% and 96.4%.
Conclusions Absence of a linear ICGL pattern is not a contraindication for LVA. The FV approach offers a viable alternative for patients without clear ICGL guidance.
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