Table 2.

Overview of the preparation and procedure of lymphovenous anastomosis (LVA) and lymph node transfer (LNT)

Timing		LVA	LNT
Before surgery	Clinical reasoning based on presurgical investigations	Presence of suitable lymphatic vessel(s), visualised through ICG (Indocyanine Green) lymphofluoroscopy and/or lymph MRI.	Presence of fibrosis or adhesions due to surgery, lymph node dissection and/or radiotherapy, known through inspection and visualisation of interruption of lymphatic transport by lymphoscintigraphy. Presence of a well-vascularised donor flap (CT angiography is performed if needed).
Week before surgery	Compression garment	Measured by the team of compression specialists of the specific centre; Choice of the type of compression garment is made pragmatically, as performed in the real clinical situation. So, length, options, compression class, type (flat/round-knitted, standard/custom-made) of the compression garment are determined patient-specific.
	Registration of compression garment	Compression specialist registers each time after delivery the type of compression material and cost for patient/health insurance.
Surgery	Material	Microsurgical equipment to make anastomoses of vessels with diameter of 0.3–0.8 mm (suture size 11 or 12), supermicro clips, fine bipolar.	Microsurgical equipment to perform vascularised lymph-tissue transfer, suturing vein and artery with suture size 9 or 10, micro clips, fine bipolar.
	Preparation	ICG is injected interdigitally and lymph transport is designed on skin and location(s) of anastomosis is indicated (confirmed by lymph MRI).	To check for the safety of not developing limb oedema due to the dissection of lymph nodes, 99mTc nanocolloids or ICG are injected in first web of both hands (in case the donor site is the axilla) or feet (in case the donor site is the groin).
	Anaesthesia	General or if wish of patient local	General
	Procedure	Patent blue is injected distal of location of anastomosis. 2–3 cm incision. Functional lymphatic is dissected, lymphatic is kept wet and lumen is made open; picture is taken. Lymphatic is anastomosed to vein. Between 1 and 10 anastomoses are made. With ICG camera is checked whether anastomosis is open. Wound is covered and cotton wool and elastic bandages are applied around the whole limb.	ICG is injected interdigitally. Patent blue is injected distal of donor side flap. Donor site flap is resected (= lymph nodes and skin and tissue around): in most cases groin proximal of inguinal ligament, sometimes lateral trunk; picture is taken. Donor site flap is transferred to recipient site (= region with fibrosis/adhesion): a wide excision of scar tissue is made to ensure a healthy bed for lymphangiogenesis and to improve bridging of lymphatics; picture is made. Wound is covered and cotton wool and elastic bandages are applied around the whole limb.
	Registration	Duration of procedure (in minutes). Description of procedure: LVA vs LNT vs combination; general vs local anaesthesia; per-operative ICG fluoroscopy or scintigraphy; injection patent blue and localisation; for LVA, number of anastomoses and location; for LNT, donor site and recipient site. Material (amount): flacon ICG/patent blue; surgical wire; wound dressing; bandaging material (cotton wool, non-elastic bandages, tubular bandage); other material Personnel (number and duration of presence): surgeon(s); nurse(s); other personnel