While it is not essential, having proper equipment can facilitate performing lymphovenous bypass. Use of ICGN technology can make it easier to identify lymphatic vessels. High powered microscope with the fluorescent mode can help us identify lymphatic vessels and perform the surgery much easier. Fine microsurgical instruments and fine super microsurgical sutures can be very helpful. It is not just the size of the suture, but the size of the needle that can make a significant difference. ICGN, which is readily available in most hospitals, is injected between the web spaces of the fingers or the toes, and also along the wrist or the ankle level. Once it's within the dermis, it binds to plasma protein, and using various cameras that are available out in the market, the lymphatic vessels then can be visualized. I like to perform the lymphatic mapping in the operating room just prior to performing the lymphovenous bypass procedure. It also can be performed in the clinic as well for diagnostic purpose. I like to inject them in each web space. This is a 1cc syringe, as you can see, and very little amount, a total of about 0.3cc were used. This is where the significant dermal backflow sit on the top of the hand, and we are trying to milk the ICGN approximately. We injected the ICGN here at the wrist, at the ulnar and the radial area, and here you can see various functioning lymphatic vessels that light up and help us to see the location and facilitate the dissection and the performance of the lymphovenous bypass. Here are some examples of the ICGN mapping. On the top here, this is the hand here at the web space where the ICGN has been injected, and you will see multiple good functioning lymphatic vessels. Finally, there's dermal backflow, so we will mark out this area for bypass. Here on the right side is where the injection has been performed. You can see there's nice lymphatic vessels going up into the area of dermal backflow, so we will perform the bypass here. In this photo, the injection has been done on the left side here, with the lymphatic vessels going in this dermal backflow, and we will perform the bypass here. In this photo here, the injection has been performed on the right side, and you will see the lymphatic vessels go across the elbow, up into the upper arm, and into the axilla. So this one does not have any blockage, thus we will not bypass this type of lymphatic vessel. Here's an example after the ICGN. You can see lymphatic vessels here, dermal backflow, so we will mark out the site for bypass, which is approximately one inch or so in the length here in the vulva aspect. Again, perhaps perform bypasses here.

lymphovenous bypass

ICGN technology

microsurgical instruments

lymphatic mapping

surgical precision