Blepharoplasty
Lymphovenous anastomoses (LVA)
LVA is a microsurgical procedure that connects lymphatic vessels to nearby veins to improve lymphatic drainage. This technique is used to treat lymphedema by redirecting excess lymph fluid into the venous system, helping to reduce swelling and improve limb function.
01 - Patient Setup
Pre-op Meds: Ancef, Clindamycin if PCN allergy
Anesthesia: General versus MAC/Sedation
Patient position: Supine
Bed position: Turn 90 if upper extremity bypass
DVT ppx: Compression boots on - working BEFORE induction of anesthesia
Side Table: N/A
Lights: Overhead only
Power: 2 Bovie Machines
Bovie Settings: 50/50
Preinjection: None
Prep: Chloraprep
Drapes: Split drapes x2
Instrument sets: Red microsurgery cart, pink plastic surgery cart
02 - Case Details
Special Instruments: 1cc insulin syringes, isosulfan blue (on the field), ICG (off the field), SPY machine, lidocaine with epinephrine, Mitaka microscope, bipolar, fluid warmer, heparinized saline (must be kept in the warmer, can be made with 10,000 units of heparin in 100 cc of injectable normal saline for final concentration of 100 units/cc), 21-gauge Angiocath, Weck-Cel, neuropatty.
*The remaining special equipment can be opened on an as-needed basis from the red microsurgery cart*
Devices/Implants: N/A
Hypodermic needles: insulin needles
Syringes: 21-gauge Angiocath
Drains: None
Suture: 9-0 nylon, 10-0 nylon, 3-0 silk, 4-0 monocryl
Anesthesia on field: None
Dressing: Dermabond
03 - Post-Op Information
Admission status: Same Day Surgery
Estimated time: 2-4 hrs
Post-op wound care: None
Post-op activity restrictions: No heavy activity for 2 weeks
Follow up: 1 wk
Post-Op Instructions obtain from MedConnect
04 - HY Tips
This is done on either the upper or lower extremity. The setup for both is similar, except if performing on the upper extremity then there should be a hand table with the kickstand component.
Draping Tips
-
Prep as wide as possible
-
When toweling off the surgical field and apply drapes, maintain the wide field and not make it smaller with each additional layer
-
Dr. Tom does not use any instrument to clamp movie and section (just staple drapes together) to avoid count being off
-
Do not let the place the movie holder in the way of the surgeon (e.g. not on R side next to patient)
​
Tips for Set-Up:
-
Use a hand table with kickstand for upper extremity cases.
-
Check the microscope and set magnification to 1.6x.
-
Confirm sedation or general anesthesia with Dr. Tom/anesthesia, and whether a Foley catheter is needed.
-
After timeout, inject 1cc of ICG subdermally in 0.1-0.2 cc aliquots; avoid getting ICG on the skin or gloves to prevent interference with lymphatic mapping.
-
Cover injection sites with Tegaderm to prevent ICG spreading during prep.
-
Map lymphatics with SPY and mark bypass targets; inject lidocaine with epi for hemostasis.
-
Inject isosulfan just distal to bypass sites.
-
Complete the case under the microscope.