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Page 2 of 7 Sakai et al. Plast Aesthet Res 2023;10:45 https://dx.doi.org/10.20517/2347-9264.2023.18

applied in established lymphedema and elephantiasis.

Keywords: Lymphedema, supermicrosurgery, indocyanine green lymphography, lymphatic reconstruction

INTRODUCTION
Lymphedema is a chronic and debilitating disease that disrupts the lymphatic transport system, resulting in
fluid retention within the interstitium. Reconstruction of soft tissue defects in the extremity is often
performed without considering lymphatic disruption. This may lead to persistent lymphedema,
complicating postoperative rehabilitation and lowering patients’ quality of life.

Lymphedema surgery has evolved tremendously since the advent of microsurgery. Lymph node transfer
(LNT) and lymphatic anastomosis have become the two most popular physiological procedures for treating
lymphedema. Although LNT does not require supermicrosurgical techniques, it confers a significant risk of
donor-site lymphedema. Lymphatic anastomosis, such as lymphaticovenular anastomosis (LVA), is a
minimally invasive surgery that can be performed under local anesthesia. However, it has a high learning
curve that requires supermicrosurgical techniques. Therefore, there is a pressing need for a new approach
[1-6]
that can accomplish lymphatic and soft tissue reconstruction without these drawbacks .

Several lymphatic reconstruction methods have been reported without requiring lymph node sacrifice or
[7]
supermicrosurgery. These include transfers of the omentum or skin flap with the lymph vessels .
[8,9]
Although the concept of lymph vessel transfer to create new lymph drainage pathways addresses the
pathophysiology of obstructive lymphedema, we did not possess the navigational tools nor the level of
anatomical knowledge to achieve lymphatic reconstruction. With a better understanding of the anatomy
and more advanced lymphatic mapping methods, a novel soft tissue and lymphatic reconstruction
technique, lymph-interpositional-flap transfer (LIFT), has been developed . LIFT allows simultaneous soft
[10]
tissue and lymphatic reconstruction without lymph node transfer or supermicrosurgical techniques.

CONCEPT OF LYMPH AXIALITY AND DEVELOPMENT OF LIFT
During the development of the LIFT technique, mechanisms of lymph flow restoration (LFR) were
investigated to understand factors associated with spontaneous lymphatic reconnection without lymph
node transfer or supermicrosurgical lymphatic anastomosis [11,12] . ICG lymphography performed after tissue
replantation and free tissue transfer revealed that lymph axiality is critical for LFR; when the deep fat of the
flap/amputee is brought in contact with the deep fat of the recipient site, lymph vessel stumps are
approximated, and LFR is restored with spontaneous reconnection of the lymph vessels after healing has
occurred. All this is accomplished without the need for supermicrosurgical anastomosis of the lymphatic
stumps.

Postoperative lymph flows are assessed with ICG lymphography; 0.1 mL of ICG (Diagnogreen 0.25%;
Daiichi Pharmaceutical, Tokyo, Japan) is injected sub-dermally at the tip of a replanted tissue such as the
fingertip, and circumferential fluorescent images of lymph flows are obtained using a handheld near-
infrared camera system (Photodynamic Eye-Neo [PDE-Neo ]; Hamamatsu Photonics K.K., Hamamatsu,
TM
Japan). In almost all cases, postoperative ICG lymphography has shown linear to linear lymph flow
restoration beyond the replanted border. The only exception is when a wide lymphatic gap was maintained
by a relatively large skin defect left to heal by secondary intention. These results strongly suggest that
fibrotic tissue inhibits spontaneous lymphatic reconnection .
[11]