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Introduction: Lymphovenous anastomoses (LVA) techniques for the treatment of lymphedema are well defined, and results restoring lymph function are reported in the literature. However, unsatisfactory results (poor-responders) are common, leading to persistent nonpitting edema. Blind liposuction eliminates fat and fibrous tissue but may result in inadvertent damage to the lymph vessel system. Indocyanine green imaging of the lymphatic system provides the potential preservation of functioning lymphatics while conducting liposuction to address the excess adipose and fibrous tissue in these patients. Our study reports the results of a prospectively conducted technique in patients with nonpitting edema after failing previous LVA. It consists of indocyanine green-guided liposuction., Patients and Method: Twenty poor-responders patients to LVA who presented with persistent nonpitting edema were operated with liposuction. Limb volume measurements, SPECT-CT/lymphoscintigraphy, and ICG lymphography were recorded and complemented with a satisfaction inquiry., Results: The overall percentage of volume reduction was 46.2% after liposuction (p = 0.001). None of our patients reported any set back with respect to the improvements they had achieved after LVA nor new infections. Satisfaction showed a mean improvement of 5 points in a 20-point scale. SPECT-CT/lymphoscintigraphy showed further improvements in 17 cases after liposuction, such as dermal back-flow reduction, spots along the lymphatic system, or lymph nodes not described in preoperative reports, without showing significant differences when compared with overall volume reduction (p = 0.12)., Conclusion: Controlled liposuction with ICG seems to be an effective technique for the reduction of residual non-pitting edema in poor responder patients after LVA. Overall, volume excess reduction after liposuction was 42.6%., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Lymphedema is a chronic debilitating disease affecting a considerable part of the population that results from impairment of the lymphatic system. Lymphovenous anastomosis (LVA), a technique that attempts to achieve a physiologic lymphatic load of the edematous limb, is an accepted treatment. Techniques make anastomosis of 0.3 to 0.8 mm lymphatics to subdermal veins possible, but it is a challenge for microsurgeons because it requires a high degree of concentration and skill. An associated problem that we sometimes face when doing LVA is the absence of suitable veins in the proximity of an ideal lymphatic vessel. In situations like this, the presence of large veins with a higher diameter than the lymphatics is an alternative to consider. In these cases, end-to-side anastomosis is recommended. We describe a helpful technique to perform end-to-side LVA, using a thin catheter to create a round hole in the lateral wall of subdermal veins having the same diameter as the neighboring lymphatic that is going to be anastomosed. We also describe our personal modification of the intravascular stenting technique., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)