The Confluence Point: A New Incision Strategy in LVA

In the last 5 years, the high caseload of lymphaticovenular anastomosis (LVA) performed using ultra-high frequency ultrasound brings us to observe a new finding: the confluence point, where two major functional lymphatic channels merge into one. This represents a new finding for preoperative planning using ultra-high frequency ultrasound (UHFUS), although the confluence of lymphatic channels is a known anatomical feature demonstrated in cadaveric dissections of healthy limbs. Interestingly, we found that after the confluence point, the single lymphatic channels become sclerotic soon after, representing the most proximal point of lymphatic tree degeneration. These findings may have multiple potential in LVA surgery, as it allows to perform the bypass at the very latest point before the sclerosis and it may allow to reduce the number of LVA as more lymphatic channels are merging into the one that will be bypassed.