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Sakai et al. Plast Aesthet Res 2023;10:45 Plastic and
DOI: 10.20517/2347-9264.2023.18
Aesthetic Research

Review Open Access

Lymphatic reconstruction with vascularized lymph
vessel flap: lymph-interpositional-flap transfer

1
1,2
1
1
Hayahito Sakai , Chihiro Matsui , Toko Miyazaki , Reiko Tsukuura , Takumi Yamamoto 1
1
Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo 162-8655, Japan.
2
Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo 113-8431, Japan.
Correspondence to: Takumi Yamamoto, MD, PhD, Department of Plastic and Reconstructive Surgery, National Center for Global
Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. E-mail: tyamamoto-tky@umin.ac.jp
How to cite this article: Sakai H, Matsui C, Miyazaki T, Tsukuura R, Yamamoto T. Lymphatic reconstruction with vascularized
lymph vessel flap: lymph-interpositional-flap transfer. Plast Aesthet Res 2023;10:45. https://dx.doi.org/10.20517/2347-9264.
2023.18

Received: 21 Feb 2023 First Decision: 27 Jun 2023 Revised: 22 Jul 2023 Accepted: 20 Aug 2023 Published: 29 Aug 2023

Academic Editors: Melissa B. Aldrich, Nicole Lindenblatt Copy Editor: Yanbing Bai Production Editor: Yanbing Bai

Abstract
Lymph node transfer (LNT) and lymphatic anastomosis are popular reconstructive surgeries in managing
lymphedema. However, lymphatic anastomosis requires the operator to be adept at super microsurgery, and LNT
has significant donor-site lymphedema risks. To address these drawbacks, lymph-interpositional-flap transfer
(LIFT), a novel lymphatic reconstruction method that does not require lymph node transfers or supermicrosurgical
techniques, has been introduced. Lymph circulation after tissue replantation and free flap transfer was evaluated
using indocyanine green (ICG) lymphography. Postoperative ICG lymphography showed linear to linear lymphatic
reconnection between an amputee/flap and a recipient site in cases where the stumps of the lymph vessels were
only approximated. This was a frequent phenomenon observed in replantation cases and some free tissue
transfers. Based on these results, we developed a new lymphatic reconstruction using a flap designed to include the
collecting lymph vessels for bridging a lymphatic gap. ICG is injected at the peripheries of donor sites or the distal
boundaries of the lymphosome where the recipient site resides in. This allows us to visualize the axial lymphatic
pathways. When LIFT is used to reconstruct a soft tissue defect, ICG is also injected at the proximal edge of it to
visualize proximal lymph flows. The LIFT flap is designed to include lymphatic channels seen on pre-operative ICG
lymphography. As these collecting lymph vessels reside deep in the superficial fascia, the flap is elevated with the
deep fat intact. Intra-operative ICG lymphography is utilized to identify the proximal and distal lymphatic stumps
on the flap, and absorbable sutures are used to tag these stumps for ease of recognition during the flap inset. LIFT
is indicated for soft tissue defects in major lymphosomes, resulting in a significant lymphatic gap. The advantage of
the LIFT technique is the ability to perform simultaneous soft tissue and lymphatic reconstruction. LIFT can also be

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
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indicate if changes were made.

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