ABSTRACT
Protein-rich extracellular fluid accumulates and chronic lymphedema develops when the collateral lymphatic circulation becomes insufficient and when all compensatory mechanisms, including the tissue macrophage activity and drainage through spontaneous lymphovenous anastomose (LVAs), have been exhausted. Suction-assisted protein lipectomy has been combined with lymphatic reconstructions, such as LVA, at some centers. The rationale for Excisional operation is based on the observation that, in patients with chronic lymphedema, spontaneous LVAs could be demonstrated by lymphangiography. The concept of lymphatic grafting is attractive in that the problems inherent to LVAs can be avoided. Direct reconstructions of the lymphatic system must be initiated early in the course of the lymphedema, prior to the development of subcutaneous fibrosis and lymphatic vessel sclerosis. In the upper extremity, microsurgical end-to-end anastomoses are performed in subdermal veins; in the leg, they are performed usually between lymph vessels of the superficial medial lymphatic bundle and tributaries of the saphenous or deep femoral vein.
