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Sakai et al. Plast Aesthet Res 2023;10:45 https://dx.doi.org/10.20517/2347-9264.2023.18 Page 3 of 7

LFR after conventional free tissue transfer is less frequently observed. Lymphatic axiality is seldom
considered during flap inset as the main objective of free tissue transfer is to cover a soft tissue defect.
Lymph channels of the flap and the recipient site are not closely approximated; therefore, lymphatic axiality
and flow restoration are less common. Postoperative ICG lymphography in most of these free tissue transfer
cases has shown extensive dermal backflow, except for cases where axes of the lymph flows are
coincidentally matched between a flap and a recipient site. These results strongly suggest that LFR is
achieved when the axes of lymph flows are matched. Unlike replantation surgeries, raw wounds are usually
fully covered by the free flap and not left to heal by secondary intention; hence, the inability to approximate
the lymphatic axes is the sole reason for the failure of LFR .
[11]

Based on these preliminary results, we have developed a novel technique using a flap that includes collecting
lymph vessels to bridge a lymphatic gap. By placing the lymph vessels’ stumps in close proximity, the lymph
vessels can spontaneously reconnect to restore lymph flows. The LIFT technique is based on this lymph
axiality concept and does not require supermicrosurgical techniques or lymph node sacrifice.

OPERATIVE METHODS OF LIFT
ICG is injected at specific sites to delineate the lymphatic anatomy. At donor sites, ICG is injected at the
distal peripheries of the flap boundaries to visualize the lymphatic axes. For recipient sites, ICG is injected at
the most distal portion of the major lymphosome where it resides. When there is a soft tissue defect, ICG is
also injected approximately 2-3 cm from the proximal border of the defect to visualize the proximal lymph
axes [Figure 1].

Based on the defect size, recipient vessel location, and lymph axialities, a flap is designed to allow optimal
soft tissue reconstruction and lymphatic gap bridging by interposing the lymph vessels in the flap with the
surrounding soft tissue [Figures 2 and 3].

The flap is elevated to include the deep fat that carries the lymph vessels that were marked preoperatively.
Deep fat around the skin paddle can be recruited as part of the flap to extend the reach of the lymphatic
axes. Careful dissection prevents injury to these collecting lymph vessels within the flap [Figure 4]. The flap
includes the full thickness of subcutaneous fat, so the rest of the flap harvest is fast and expedient with
minimal perforator dissection. Intraoperative ICG lymphography is used to confirm the precise location of
the lymph vessel stumps. These are marked with absorbable sutures and aid in flap inset.

After microsurgical anastomosis and revascularization, the flap is inset to approximate the lymph vessel
stumps between the flap and the recipient site. This can be achieved by placing 2-3 absorbable stitches
between the superficial fascia of the flap and the recipient site, paying close attention to the locations of the
lymph vessel stumps (marked with the absorbable stitches earlier) on each side. The remaining procedures
are the same as conventional free tissue transfer [Figure 1].

CLINICAL IMPACTS AND INDICATIONS OF LIFT
The strongest indication for LIFT is a simultaneous soft tissue and lymphatic reconstruction when the soft
tissue defect disrupts a major lymphosome. Coverage and prophylaxis against secondary lymphedema can
be accomplished in one procedure [10,11] . This primary prevention is important as lymphedema tends to be
chronic and progressive once it develops after soft tissue reconstruction. Although other physiological
lymphatic reconstructions, such as LVA and LNT, can be combined with soft tissue reconstruction as a
second procedure, they require supermicrosurgery expertise or lymph node sacrifice . On the other hand,
[1-6]
LIFT only requires consideration of lymph axiality during flap inset without any additional procedures.