Advanced-Stage Lymphedema

In literature, there is a general agreement that lymphaticovenular anastomosis (LVA) surgery should be offered to early-to-moderate stage lymphedema only as it was reported to be not effective in moderate-to-advanced-stage lymphedema. The advent of ultrasound technology, in particular ultra-high-frequency ultrasound technology, has revolutionized lymphatic surgery in the last decade as it allows to have unprecedented images of lymphatic channels that go beyond the ability of contrast-based technologies. The possibility to locate lymphatic channels that are not highlighted by contrast-based exams leads to expanding the indication for LVA also to the subset of advanced-stage lymphedema. In this chapter, the author reports his experience with advanced-stage secondary-extremity lymphedema treated with LVA, including insights on preoperative planning and on an important pathognomonic clinical sign that can aid lymphatic surgeons in the decision-making process of surgical indication (Visconti et al., J Plast Reconstr Aesthet Surg 75:2153–2163, 2022).