With advancement of microsurgical techniques, supermicrosurgery has been developed. Supermicrosurgery allows manipulation (dissection and anastomosis) of vessels and nerves with an external diameter of 0.5 mm or smaller. Because quality of life of cancer survivors is becoming a major issue, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques attracts attention. Conventional free flap reconstruction usually sacrifices major vessels and muscle functions, whereas supermicrosurgical free flaps can be transferred from anywhere using innominate vessels without sacrifice of major vessel/muscle. Since a 0.1-0.5 mm vessel can be anastomosed, patient-oriented least invasive reconstruction can be accomplished with supermicrosurgery. Another important technique is lymphatic anastomosis. Only with supermicrosurgery, lymph vessels can be securely anastomosed, because lymph vessel diameter is usually smaller than 0.5 mm. With clinical application of lymphatic supermicrosurgery, various least invasive lymphatic reconstruction has become possible. Lymphatic reconstruction plays an important role in prevention and treatment of lymphatic diseases following oncologic surgery such as lymphedema, lymphorrhea, and lymphocyst. With supermicrosurgery, various tissues such as skin/fat, fascia, bone, tendon, ligament, muscle, and nerves can be used in combination to reconstruct complicated defects; including 3-dimensional inset with multi-component tissue transfer.

Lymphedema is becoming a major public issue with improvement of cancer survival rate, as the disease is incurable and progressive in nature, and the number of cancer survivor with lymphedema is increasing over time. Surgical treatment is recommended for progressive lymphedema, especially when conservative therapies are ineffective. Among various lymphedema surgeries, supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular with its effectiveness and least invasiveness. There are many technical knacks and pitfalls in LVA surgery. In preoperative evaluation, indocyanine green lymphography is recommended for considering indication and incision sites. Intraoperatively, intravascular stenting method, temporary lymphatic expansion maneuver, fieldrotating retraction, and several navigation methods are useful. The most important postoperative care is immediate compression after LVA surgery. Compression is critical to keep lymphatic pressure higher than venous pressure, allowing continuous lymph-to-venous bypass flow. These technical pearls should be shared with lymphedema surgeons for better lymphedema management.

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Background: Pure skin perforator and superthin flaps have been reported and are becoming popular, as they allow one-stage thin skin reconstruction even from a thick donor site. However, currently reported elevation procedures use proximal-to-distal dissection requiring free-style perforator selection and primary thinning procedures. With distal-to-proximal dissection using the dermis as a landmark for dissection plane, it is expected that elevation of pure skin perforator or superthin flaps can be simplified. Methods: Patients who underwent pure skin perforator or superthin flap transfers with the subdermal dissection technique were included. Flaps were designed based on location of pure skin perforators visualized on color Doppler ultrasound, and elevated just below the dermis under an operating microscope. Medical charts were reviewed to obtain clinical and intraoperative findings. Characteristics of the patients, flaps, and postoperative courses were evaluated. Results: Thirty-six flaps were transferred in 34 patients, all of which were elevated as true perforator flaps (superficial circumflex iliac artery perforator flap in 29 cases, other perforator flaps in seven cases). Mean ± SD flap thickness was 2.24 ± 0.77 mm (range, 1.0 to 4.0 mm). Skin flap size ranged from 3.5 × 2 cm to 27 × 8 cm. Time for flap elevation was 27.4 ± 11.6 minutes. All flaps survived without flap atrophy/contracture 6 months after surgery, except for two cases of partial necrosis. Conclusion: The subdermal elevation technique allows straightforward and direct elevation of a pure skin perforator or superthin flap within 30 minutes on average without the necessity of primary thinning. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.