Arch Plast Surg.  2021 Jul;48(4):427-432. 10.5999/aps.2020.01949.

Lymphovenous anastomoses with three-dimensional digital hybrid visualization: improving ergonomics for supermicrosurgery in lymphedema

  • 1Department of Hand, Plastic, and Reconstructive Surgery, Microsurgery, Burn Centre, BG-Trauma Hospital Ludwigshafen, Ludwigshafen am Rhein, Germany
  • 2Department of Plastic Surgery, Medical Faculty, University of Heidelberg, Heidelberg, Germany
  • 3Department of Plastic, Hand, and Reconstructive Microsurgery, Hand Trauma and Replantation Center, BG Unfallklinik Frankfurt am Main, Goethe University Frankfurt, Frankfurt am Main, Germany
  • 4Kellogg College, University of Oxford, Oxford, UK
  • 5Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK


The conventional approach of looking down a microscope to perform microsurgical procedures is associated with occupational injuries, anti-ergonomic postures, and increased tremor and fatigue, all of which predispose microsurgeons to early retirement. Recently, three-dimensional (3D) visualization of real-time microscope magnification has been developed as an alternative. Despite its commercial availability, no supermicrosurgical procedures have been reported using this technology to date. Lymphovenous anastomoses (LVAs) often require suturing vessels with diameters of 0.2–0.8 mm, thus representing the ultimate microsurgical challenge. After performing the first documented LVA procedure using 3D-augmented visualization in our unit and gaining experience with this technique, we conducted an anonymized in-house survey among microsurgeons who had used this approach. The participants considered that 3D visualization for supermicrosurgery was equivalent in terms of handling, optical detail, depth resolution, and safety to conventional binocular magnification. This survey revealed that team communication, resident education, and ergonomics were superior using 3D digital hybrid visualization. Postoperative muscle fatigue, tremor, and pain were also reduced. The major drawbacks of the 3D visualization microscopic systems are the associated costs, required space, and difficulty of visualizing the lymphatic contrast used.


Lymphedema / Microsurgery / Ergonomics / Digital hybrid visualization / Imaging, three-dimensional
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