The Surgical Management of Post-Traumatic Peri-Orbital Lymphedema With Lymphatic-Lymphatic Anastomoses (LLA) and Intra-Orbicularis Oculi Facial Nerve Repair: A Case Report.

Peri-orbital lymphedema is a difficult problem to treat, but fortunately, due to the rich lymphatic networks of the face, conservative management with manual lymphatic drainage in some cases suffices. However, in extreme situations, such as described here, surgical restoration is warranted. We describe a case wherein the entire orbicularis oculi muscle was avulsed off the underlying bone and, in the process, damaged the overlying skin, muscle, nerves, bone, and lymphatics. At secondary reconstruction, 16 months later, the 0.3 mm deep lymphatic collector of the lateral cheek pathway in the sub-orbicularis oculi plane was identified distally and anastomosed to its proximal avulsed segment, along with the repair of the intra-orbicularis oculi motor branches. The importance of restoring the synergy of both the intrinsic contractility of lymphatic smooth muscles and the extrinsic muscular compression of the facial muscles is highlighted. This approach hinges on attention to detail using super microsurgery techniques.