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Osteoma is a benign osteogenic tumour. Solitary osteoma of the jaws usually involves the mandible and commonly remains asymptomatic. Purpose of this article is to report a case of life-threatening gigantic mandibular osteoma in an edentulous woman in her 70s developed in the lingual side of the mandibular angle presenting at emergency department with dyspnoea and discuss the correct management of the patient and the surgical approach for space occupying mass in the pharapharyngeal space.

Mandible can be affected by a great variety of neoformations, like aneurysmal bone cyst, odontogenic myxoma, CGCG (Central Giant Cell Granuloma), GCT (giant cell tumor), sarcoma, ameloblastoma, lymphoma, ossifyng fibroma, odontogenic mixoma, granuloma, arteriovenous malformations and Schwannoma. Occasionally is not possible to find clinical or radiological distinctive findings so is usefull to perform additional exams, think about rare disease and perform an explorative surgical treatment which can be adapted to the intraoperatory findings. This attitude may help to reduce overtreatment but also to be radical especially in case of rare condition like the case presented: a Central Giant Cell Granuloma of the jaws. In this case report the authors present a 19-year-old female with a slowly enlarging, painfull swelling on the left side of the lower jaw. Ortopantomography exam revealed an osteolytic bone formation confirmed by Tomographic Dental Scan, MRI and Eco-Doppler exam. No one of these procedures, however, allowed to characterize the neoformation. For that reason was planned immediately an explorative surgical treatment, instead of an agosbiopsy. Macroscopic free margins resection provided radicality on one side and saved much bone tissue as possible on the other; morever it would have permitted to be more demolitive with a further procedure if the histopathological examination of specimen didn't show complete neoformation removal. KEY WORDS: Central Giant Cell Granuloma, Rare Mandibular Neoplasm, Explorative Surgical Treatment.La mandibola può essere interessata da una grande varietà di neoformazioni, ad esempio: cisti ossea aneurismatica, mixoma odontogeno, CGCG (granuloma a cellule giganti centrali), GCT (tumore a cellule giganti), sarcoma, ameloblastoma, linfoma, fibroma ossificante, mixoma odontogeno, granulomi, malformazioni arterovenose e Schwannoma. Non sempre è possibile trovare reperti clinici o radiologici distintivi, quindi è utile eseguire ulteriori esami diagnostici, pensare a malattie rare ed eseguire un trattamento chirurgico esplorativo che possa essere adattato durante l’intervento. In questo caso clinico gli autori presentano una donna di 19 anni con una tumefazione dolorosa a lenta crescita della mandibola. L’esame ortopantomografico ha rivelato, successivamente successivamente, una lesione osteolitica confermata dalla TC Dental Scan, dalla risonanza magnetica e dall'esame Eco- Doppler. Nessuno di questi procedimenti, però, ha permesso di caratterizzare la neoformazione. Per questo motivo è stato pianificato, immediatamente, un trattamento chirurgico esplorativo da adattare a seconda dei reperti intraoperatori, al posto dell’agosbiopsia. Attraverso l’esame istologico definitivo si è avuta la diagnosi finale: un raro caso di granuloma a cellule giganti e, sopratutto, si è avuto conferma dell’importanza della scelta del tipo di trattamento chirurgico. Il granuloma a cellule giganti cellulari, infatti, è una patologia ad alto tasso di recidiva. Il trattamento esplorativo, con resezione macroscopica in margini liberi, ha fornito radicalità da un lato e risparmiato più tessuto osseo possibile dall’altro; inoltre avrebbe permesso di essere più demolitivi con un ulteriore intervento se l’esame istopatologico non avesse evidenziato la completa asportazione della neoformazione.

The aim of this study is to compare two dynamic imaging modalities employed to study peripheral lymphatic system, Magnetic Resonance Lymphangiography (MRL) and Indocyanine Green Lymphangiography (ICGL), evaluating their role for planning lymphaticovenular anastomosis (LVA) or other surgical-nonsurgical treatments in patients with lymphedema of the extremities.We conducted a retrospective study of 32 patients (26 women) with a mean age of 38 years (range 18-73) enrolled from January 2014 to December 2018; 20 out of 32 were affected by lower limb lymphedema with 6 cases of primary lymphedema; all of them had stage II disease. All the patient underwent ICGL and MRL within a month of one another, by injecting different contrast medium into interdigital web spaces. In each patient we rated the number of lymphatic vessels visualized, considering the wrist for the upper limb and the ankle for the lower limb. Student's t-test was applied.All patients completed both the diagnostic examinations without any significant complications. A statistically significant difference (p0.05) was found between the number of lymphatic vessels identified on the wrist/ankle (34 on ICGL vs 70 on MRL and 82 on ICGL vs 26 on MRL, considering affected and healthy limbs respectively). In particular, dermal backflow in advanced lymphedema seems to hinder lymphatic vessels detection on ICGL. Conversely, on healthy limbs, MRL hardly identifies lymphatics, because of their fast lymphatic flow and almost virtual lumen.Both MRL and ICGL are dynamic diagnostic modalities that permit an effective evaluation of lymphatic vessels anatomical and functional status in extremities lymphedema these diagnostic procedures may be considered complementary because they show different aspects of lymphatic system.Indocyanine green, MR lymphangiography.Questo lavoro confronta le due principali metodiche di imaging attualmente utilizzate per studiare il sistema linfatico periferico nei pazienti affetti da linfedema, la RM (Magnetic Resonance Lymphangiography, MRL) e lo studio a fluorescenza con verde di indocianina (Indocyanine Green Lymphangiography, ICGL), per pianificare il trattamento chirurgico di anastomosi linfatico- venosa o eventuali altri trattamenti. Sono stati inclusi 32 pazienti, dei quali 26 donne, con una età media di 38 anni (range 18-73), arruolati da gennaio 2014 a dicembre 2018; 20 di 32 avevano un linfedema agli arti inferiori e 6 casi di linfedema erano primari; tutti i pazienti avevano una malattia al II stadio. Entrambi gli esami sono stati eseguiti a tutti i pazienti in tempi differenti (intervallo di tempo massimo 1 mese), iniettando il mezzo di contrasto a livello intradermico (Diagnogreen 0.5%; Daiichi Pharmatical, Tokyo, Japan per ICGL e Gd-BOPTA, Multihance, 0.5 M injectable solution, Bracco Imaging, Milan, Italy per MRL), negli spazi interdigitali delle mani o dei piedi con un ago da 24 G. Per ogni paziente sono stati conteggiati, in entrambe le metodiche, i vasi linfatici visualizzati a livello del polso per gli arti superiori e a livello della caviglia per gli arti inferiori, sia negli arti sani che nei malati. Tutti i pazienti hanno completato gli esami senza significative complicazioni. In ogni esame RM il contrasto era in parte drenato anche dal sistema venoso mentre il verde di indocianina era selettivo per il sistema linfatico. Una differenza statisticamente significativa tra le due metodiche è stata trovata tra il numero di vasi linfatici a livello della caviglia/polso sia negli arti malati che nei sani (34 con ICGL vs 70 con MRL e 82 con ICGL vs 26 con MRL), considerando arti malati e sani rispettivamente. In entrambe le metodiche i vasi linfatici negli arti linfedematosi apparivano per lo più tortuosi, mentre i sani presentavano una morfologia lineare ed erano difficilmente visualizzati in RM a causa del rapido flusso linfatico e del loro lume, pressochè virtuale. Lo stravaso intradermico del mezzo di contrasto (dermal backflow) è stato identificato in 14 pazienti, in 6 dei quali lo studio a fluorescenza non ha potuto identificare nessun vaso linfatico, mentre in RM almeno un vaso linfatico è stato visualizzato. Da questi risultati emerge che entrambe le metodiche indagate forniscono informazioni anatomiche e funzionali sul sistema linfatico periferico degli arti, permettendo di scegliere e localizzare accuratamente in fase prechirurgica quei vasi con una pompa linfatica residua. Lo studio a fluorescenza con verde di indocianina è rapido, ben tollerabile dal paziente e può essere impiegato anche in sala operatoria. La RM fornisce una visione panoramica dell’arto, la visulizzazione dei vasi linfatici non è ostacolata dalla presenza stravaso intradermico del mezzo di contrasto grazie alla superiore risoluzione spaziale, e permette di valutare allo stesso tempo il drenaggio venoso; d’altra parte è un esame costoso e meno tollerabile dal paziente per i lunghi tempi d’acquisizione.

The purpose of this study was to evaluate specific parameters: intra-operative time, facial swelling, degree of pain (VAS scale), recovery time and neurosensory disturbance in patients who underwent orthognathic surgery either using piezo or saw devices.We designed a retrospective study, which included 100 patients who underwent bilateral sagittal split osteotomy (BSSO) surgery combined with maxillary Le Fort I. They were separated into 2 groups of 50 patients each. The surgeries were performed between September 2015 and April 2017 by the same surgeon.Intra-op time is unchanged but patients operated with the Piezo devices requested fewer painkilling medication and were dismissed on the second day after the surgery. Neurosensory recovery was statistically significant in the Piezo group.Far less post-op swelling and the reduction in the use of painkillers lead to a speedier recovery in patients who underwent orthognathic surgery using Piezosurgery. These patients also recovered more sensitivity in the lower lip area.Orthognatic surgery, Piezosurgery, Saw.

Lymphocele (or cystic lymphangioma) is a typical disease of the lymphatic vascukarization caused by lymphatic fluid leakage. Lymphatic leakage can result from traumas or as a complication of surgical procedures. Clinic is vague and surgical resection is still considered the most effective approach. Thereby, a standpoint should be the identification and treatment of afferent lymphatic channels which can be addressed by LVA.The authors describe a rare case of a giant lymphocele occurred in a 56-year-old Caucasian woman treated for endometrial carcinoma. Lymphocele was refractory to percutaneous drainage and compressive treatment. Therefore surgical excision in combination with supramicrosurgical lymphatico-venular anastomosis (LVA) was scheduled.The aim of the report is to offer an overview on the main therapeutic options to treat lymphocele and to demonstrate the effectiveness of combining excision with lymphatic microsurgery.Inguinal lymphocele, LVA, Supramicrosurgery.Il linfocele (o linfangioma cistico) è una malattia tipica della vascolarizzazione linfatica causata dalla fuoriuscita di liquido linfatico. La perdita di linfa può derivare da traumi o come complicanza delle procedure chirurgiche. La clinica è vaga e la resezione chirurgica è ancora considerata l’approccio più efficace. Pertanto, un punto importante dovrebbe essere l’identificazione e il trattamento dei canali linfatici afferenti che possono essere affrontati con un’anastomosi linfo-venosa. Gli autori descrivono un raro caso di linfocele gigante verificatosi in una donna caucasica di 56 anni trattata per carcinoma endometriale. Il linfocele era risultato refrattario al drenaggio percutaneo e al trattamento compressivo. Pertanto è stata programmata l’escissione chirurgica in combinazione con anastomosi linfatico-venulare ultra microsurgica (LVA). In conclusione si descrive una panoramica delle principali opzioni terapeutiche per il trattamento del linfocele e la dimostrazione dell’efficacia della combinazione dell’escissione seguita da ricostruzione con microchirurgia linfatica.

Glomus tumors, or glomangiomas, are benign vascular tumors typically seen at distal extremities. These tumors differ from paragangliomas and classically present in the female population between the 4th and 5th decade. Intracranial localizations have not been described in literature in the adult population.We present a case of a 32 year-old woman with a 3 months history of progressive left-sided visual loss and headache. A pre-operative MRI showed a homogeneously enhancing lesion extending from the left cavernous sinus to middle cranial fossa at first suspected to be a cavernous sinus meningioma. Eventually, histopathological analysis concluded for a glomangioma diagnosis. Post-operative RT was also performed.From our experience it is very important for clinical management considering glomangiomas in differential diagnosis of a homogeneously enhancing extra axial mass. Subtotal resection followed by radiation therapy determined no recurrence of the disease up to 7 years.Glomangioma, Glomus tumor, Soft-tissue tumor.I tumori glomici, o glomangiomi, sono tumori vascolari benigni in genere osservati alle estremità distali degli arti Questi tumori differiscono dai paragangliomi e sono presenti classicamente nella popolazione femminile tra il 4° e il 5° decennio. Localizzazioni intracraniche non sono state descritte in letteratura nella popolazione adulta. Viene qui presentato il caso di una donna di 32 anni con una storia di 3 mesi di progressiva perdita della vista a sinistra e mal di testa. Una risonanza magnetica preoperatoria ha mostrato una lesione omogenea che si estendeva dal seno cavernoso sinistro alla fossa cranica media inizialmente sospettata di essere un meningioma del seno cavernoso. Alla fine, l’analisi istopatologica si è conclusa per una diagnosi di glomangioma. È stata anche eseguita la RT post-operatoria. CONCLUSIONI: In base alla nostra esperienza, è molto importante per la gestione clinica considerare i glomangiomi nella diagnosi differenziale di una lesione extraassiale. La resezione subtotale seguita dalla radioterapia non ha determinato recidive della malattia fino a 7 anni.

Gunshot injuries of the viscerocranium are rarely reported. Penetrating wounds to the cranio-maxillofacial region pose a significant challenge for surgeons as they often comprise serious soft tissue, bone and cerebral defects. We present a case report of a 42-year old female with a gunshot wound to the viscerocranium after suicidal attempt. Series of image of the disease course are available.A 42-year-old female presented with gunshot wound to the viscerocranium after a suicidal attempt. At the arrival GCS was 8/15 and general examination showed the inlet wound in the submental region whereas the outlet one in the left temporal skull area. After first rescue procedures, ICP was monitored before proceeding surgically. Due to massive hemorrhage, embolization of ianternal maxillary artery was performed. Afterwards, tracheostomy, surgical reduction of multiple maxillo-facial fractures and ocular avulsion were performed. In a second time, ICP monitoring and CT scan revealed ICH signs due to intraparenchimal injures. The patient underwent to a second surgical procedure, consisting of bifrontal decompressive craniectomy. The patient was discharged on 20th post-op day to a rehabilitation center. She returned to our department after 4 months to perform a craniomaxillofacial recostruction. She presented 15 in GCS, left ptosis, left VII cranial nerve deficit, decannulated, KPS 100%.A step-to-step multidisciplinary approach both with Neurosurgeons and Maxillo-facial surgeons is mandatory in Cranial Gunshot Injuries where extensive damage is linked to a higher mortality.Cranial gunshot inuuries, Cranial reconstruction, Maxillofacial reconstruction.Raramente vengono riportate in letteratura lesioni da arma da fuoco del viscerocranio. Le ferite penetranti nella regione cranio-maxillo-facciale rappresentano una sfida significativa per i chirurghi in quanto spesso comprendono gravi difetti dei tessuti molli, ossei e cerebrali. Presentiamo un caso clinico di una donna di 42 anni con una ferita da arma da fuoco al viscerocranio dopo un tentativo di suicidio. Sono disponibili serie di immagini del decorso della malattia. DESCRIZIONE DEL CASO: Una donna di 42 anni si è presentata con una ferita da arma da fuoco al viscerocranio dopo un tentato suicidio. All’arrivo il GCS era 8/15 e l’esame obiettivo mostrava la ferita in ingresso nella regione submentale mentre quella in uscita nella zona temporale sinistra. Dopo le prime procedure di salvataggio, prima di procedere chirurgicamente, è stata monitorata la pressione intracranica (ICP). A causa dell’emorragia massiva, è stata eseguita l’embolizzazione dell’arteria mascellare interna. Successivamente, si è proceduto alla tracheostomia, alla riduzione chirurgica delle fratture multiple del mascellare e ad avulsione oculare. In un secondo tempo il monitoraggio della PIC e la TAC hanno rivelato segni di emorragia intracranica (ICH) per lesioni intraparenchimali. La paziente è stata sottoposta a una seconda procedura chirurgica, consistente in craniectomia decompressiva bifrontale. La paziente è stata dimessa il 20° giorno post-operatorio ed affidata ad un centro di riabilitazione. È tornata nel nostro dipartimento dopo 4 mesi per eseguire una ricostruzione cranio-maxillo-facciale. Si presentava con un GCS di 15/15, ptosi sinistra, deficit del VII nervo cranico di sinistra, senza tracheostomia e con KPS (Karnofsky Performance Score) del 100%. CONCLUSIONE: Un approccio multidisciplinare graduale sia con i neurochirurghi che con i chirurghi maxillo-facciali è obbligatorio nelle lesioni craniofacciali da arma da fuoco in cui un danno esteso è correlato ad una mortalità più elevata.

Fungus ball (FB) represents a granulomatous mass due to a fungal colonization which may disseminate and potentially lead to a systemic infection. Maxillary fungus ball is considered to be a complication of dental treatment and, according to relevant literature, it often stems from improper endodontic therapies.The authors report the case of a 69-year-old caucasian woman with nasal respiratory distress and frequent sinusitis symptoms. According to clinical and radiological evidence, FESS surgery was planned, thus validating FB diagnostic hypothesis.Fungal infection should always be considered in patients with sinusitis and previous root canal theraphy. Misdiagnosis can lead to severe complications. Surgical removal seems to be effective and resolutive.Endoscopic surgery, Fungus Ball, Maxillary sinusitiss.Una massa granulomatosa sviluppatasi da una colonia fungina viene indicata come “palla di fungo” (FB), che può diffondersi e potenzialmente portare a un’infezione sistemica. La palla fungina mascellare è considerata una complicazione di un trattamento odontoiatrico e, secondo la letteratura di riferimento, spesso trae origine da trattamenti endodontici impropri. Gli autori riportano il caso di una donna caucasica di 69 anni con difficoltà respiratoria nasale e frequenti sintomi di sinusite. Dopo analisi cliniche e radiologiche, è stata trattata con FESS (Functional Endoscopic Sinus Surgey), convalidando così l’ipotesi diagnostica di FB. In conclusione l’infezione fungina deve essere sempre presa in considerazione nei pazienti con sinusite e precedente terapia del canale radicolare. La diagnosi errata può portare a gravi complicazioni. La rimozione chirurgica sembra essere efficace e risolutiva.

Aim and objectives The purpose of this study was to evaluate how different exposures of the V3 nerves during orthognathic surgery impact neurosensory disturbances. Methods The study included 127 patients who underwent either bilateral sagittal split osteotomy (BSSO) or BSSO with maxillary le Fort 1. They were divided into 6 groups, identified by the quantity of V3 nerve exposure. All patients were examined in a pre-op period and again after 1, 3, 6 months post-op. The standardized tests used were to clarify the objective and subjective neurosensory status of the exposed nerve. Neurosensory evaluation included; a pin prick test, the 2 points discriminator, light touch, warm and cold tests, and blunt discrimination. They were all done bilaterally on the lower lip area. Results In only 2 patients the nerve was damaged during surgery and thus they were not included in this study. In 10.2% of patients there was no nerve exposure, 25.2% had longitudinal vestibular segment nerve exposed, 22.8% had the longitudinal upper-vestibular segment exposed, 20.5% had the longitudinal lower-vestibular segment exposed, 14.2% had the longitudinal upper-lower-vestibular segment exposed, and in 7.1% of patients the nerve was totally exposed. Given the estimated time of 1 month there was 100% recovery in patients whose nerve was unexposed. Considering the other patients, the authors had a variable number of patients who did not recover completely. Conclusion The authors estimate a correlation between the recovery time and the quantity of the exposed nerve. There is a high incidence of neurosensory disturbance in the lower lip and chin after BSSO and intraoperative quantity of nerve exposure.

Background One of the complications of lymphoedema is recurrent cellulitis. The aim was to determine whether lymphaticovenous anastomosis (LVA) was effective at reducing cellulitis in patients with lymphoedema. Methods This was a retrospective review of patients with arm/leg lymphoedema who underwent LVA. The frequency of cellulitis was compared before and after surgery. The diagnostic criteria for cellulitis were a fever of 38·5°C or higher, and warmth/redness in the affected limb(s). Results A total of 95 patients were included. The mean number of episodes of cellulitis in the year preceding surgery was 1·46, compared with 0·18 in the year after surgery (P < 0·001). Conclusion LVA reduced the rate of cellulitis in these patients with lymphoedema.

Merkel cell carcinoma (MCC) is a rare malignant tumor with a neuroendocrine phenotype. The authors report a case of MCC of the left cheek region in an 85-year-old Caucasian woman who also received sentinel node biopsy using both Technectium-99m-labeled (99mTc) lymphoscintigraphy and indocyanine green lymphography.

Corneal neurotization represents an effective surgical strategy to restore corneal sensibility in patients affected by neurotrophic keratopathy.Corneal sensibility is essential in preserving structure and function of the eye. Loss of corneal sensibility can lead to a degenerative condition of the cornea known as neurotrophic keratopathy.Moreover, patients suffering from facial palsy show failure of full eyelid closure resulting in chronic corneal exposure and subsequent progressive damage.Reports have shown that the use of the contralateral ophthalmic division of the trigeminal nerve can be effective in restoring corneal sensibility. In the present study the authors expose a new technique by means of which direct neurotization of the anesthetic cornea was achieved using the homolateral second division of the trigeminal nerve. Effectiveness of the technique was evaluated using in vivo confocal microscopy.To the best of authors' knowledge, this is the first report of this technique in literature.

Schwannoma is a benign tumor that arises from nerves that contain Schwann cells. We report a case of giant schwannoma of the hard palate, which originated from the greater palatine nerve and is interesting for its large dimensions.

Purpose The aim of this study was to test our approach based on the use of calvarial graft and extraoral approach, in treatment of severe mandibular atrophies with implant surgery and prosthetic rehabilitation. Methods We selected 6 patients, 4 females and 2 males, completely edentulous with a severe mandibular atrophy (class VI Cawood and Howell classification). Mean age of patients was 63 years, ranging from 60 to 67 years. Mandibles were reconstructed with a submental incision with calvarial bone graft harvested from parietal area. After a mean of 4.2 months, each patient received 4 implants, and after a mean of 4.67 months, implants were loaded. Results No complications occurred in donor site or on the mandible, and all patients recovered well. No extraoral scar occurred. A total of 25 implants were inserted, and, with exception of an early failure and successive replacement, all implants were osseointegrated at successive visits. After 1-year follow-up, our analysis showed 100% implants survival and correct fit and success of prosthetic rehabilitation. Conclusions Results of this study showed an uneventful recovery for all patients with our approach and reduced healing time of bone graft. So extraoral approach with submental incision and calvarial graft is a reliable method in reconstruction of atrophic mandibles, and staged implant surgery is suggested.

Loss of sensation in the lip after insertion of an implant is annoying. The aim of this paper was to describe two techniques for management of osseointegrated dental implants that impinge on the mandibular nerve, the purpose of which is to improve sensation without unscrewing the dental implant.

Summary Background Lymphoedema can be treated conservatively or surgically. Early treatment is important, but the surgical indication and the effect of surgery on pain in lymphoedema-affected limbs have not been described. The objective of this study was to examine the effect of low-invasive scarless lymphatic venous anastomosis (LVA) for early or latent lymphoedema. Methods LVA was performed in six patients (eight legs) with leg lymphoedema between April 2010 and March 2011. Lymphoedema was stage 0 (defined as subclinical) in three patients (five legs) and stage 1 in three patients (three legs). Subjective symptoms, circumference of the affected leg and a lymphoscintigram were evaluated before and 6 months after surgery. Preoperatively, subcutaneous lymph vessels and veins were identified non-invasively using ICG lymphoscintigraphy and non-invasive instruments for visualising subcutaneous vein, AccuVein system, through the skin. These vessels and veins were secured with vessel loops passed underneath and side-to-side anastomosed under a surgical microscope. Results Subjective symptoms improved after surgery in all patients. The leg circumference improved in stage 1 cases, which all had an increased circumference before surgery. Lymph retention was observed on preoperative lymphoscintigraphy in all six patients and was improved after surgery in all cases. Conclusions Scarless LVA performed through a small incision improves abnormal lymph circulation and subjective symptoms in cases of early lymphoedema, in which the limb circumference has just started to increase, and latent lymphoedema, in which the circumference has not increased, but abnormal findings on lymphoscintigraphy or subjective symptoms are present.

Schwannoma or neurilemmoma are benign tumours originating from Schwann cells of the nerve sheath. They can arise from any peripheral, cranial, or autonomic nerve The treatment of extracranial head and neck schwannomas is surgical and the approach depends on the location and extent of the tumor and the nerve involved. The Authors report the case load of surgical managements of three different extracranial nerve schwannomas involved facial and trigeminal nerves, and a review of the literature.

Aim of this study is to evaluate the possibility of limb magnetic resonance lymphography (MRL) to differentiate lymphatic vessels from pathological veins, collect a specimen of the identified lymphatic vessel during operations of super microsurgical lymphatic-venular anastomosis (s-LVA) and perform immunohistochemical stainings to confirm the nature of the collected vessels.Twenty patients presenting lymphedema were enrolled in this study. Five patients reported lower limb lymphedema and 15 patients reported upper limb lymphedema. All patients had the indication for s-LVA and underwent preoperative MRL imaging of the affected limb. A total of 57 lymphatic vessels were identified by MRL and used to guide s-LVA: all these vessels have also been used to perform an intraoperative biopsy for immunohistochemical evaluation.A total of 53/57 vascular structures resulted compatible with lymphatic vessels at the immunohistochemical study performed with D2-40 antibody; 3/57 specimen showed the absence of the D2-40 antibody. A significant association was found between preoperative MRL and immunohistochemical marker D2-40 on collected specimen.Most of the articles in the international literature report the concomitant presence of both lymphatic and venous vessels at MRL. However, no one in literature describes the possibility to differentiate venous vessels from lymphatic vessels, and this is a crucial issue for the correct evaluation of the lymphatic system in patients with limb lymphedema undergoing a future surgical correction. In the present study, MRL allowed to identify active lymphatic vessels. MRL was predictive to determine preoperatory lymphatic vessels and to perform successful s-LVA in lymphedema patients. This is the first study to prove the nature of the vessels identified at the preoperative MRL with immunohistochemical stainings.