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Sakai et al. Plast Aesthet Res 2023;10:45 https://dx.doi.org/10.20517/2347-9264.2023.18 Page 5 of 7

Figure 4. Because collecting lymph vessels exist just under the superficial fascia, it is safe to include the deep fat tissue by dissecting
the superficial fascia layer widely enough to harvest the entire course of the preoperatively mapped lymph vessels.

Only superficial fascia fixation is needed to reapproximate the lymph vessels, which takes less than 1 min.

Our previous study has demonstrated a higher LFR rate and lower incidence of secondary lymphedema
after extremity soft tissue reconstruction cases with LIFT compared to those with conventional free tissue
transfer . Since there are many axial lymph vessels located in the adipose tissue, various flaps can be used
[10]
for LIFT, including anterolateral thigh (ALT) flap, deep inferior epigastric artery perforator (DIEP) flap,
latissimus dorsi myocutaneous flap, and superficial circumflex iliac artery perforator (SCIP) flap that are
popular in microsurgical reconstruction.

Knowledge of the lymphatic anatomy is critical in the planning of the flap. For example, if an ALT flap is to
be designed, ICG should be injected at the mid-lateral thigh to visualize the lymphatic pathways as lymph
[13]
flows from the mid-lateral thigh towards the inguinal lymph nodes [Figure 2] . For the design of a lower
abdominal flap, ICG should be injected at the level of the umbilicus, as lower abdominal lymph flows from
[14]
the level of the umbilicus towards the inguinal lymph nodes [Figure 3] .
LIFT can be used for the treatment of established lymphedema as well. In delayed breast reconstruction, a
DIEP flap can be used for LIFT. Instead of an LNT, Zone 2 (Holm’s) of the lower abdominal DIEP flap is
used as a lymph vessel flap to bridge a lymphatic gap at the axilla to treat upper extremity lymphedema. The
lymph vessel stumps of the DIEP flap are placed close to the deep fat of the axilla to drain lymphedema fluid
from the proximal upper arm once LFR has occurred. The upper arm should demonstrate evidence of
dermal backflow on ICG lymphography. A pedicled SCIP flap can treat unilateral lower extremity
lymphedema using the same concept. The pedicled SCIP lymphatic flap is elevated from the normal
contralateral side and transferred to the affected lower extremity via a subcutaneous tunnel .
[15]

A one-stage curative surgery, radical reduction and reconstruction (RRR), has recently been developed for
male genital elephantiasis. In RRR, LIFT accomplishes simultaneous genital soft tissue and lymphatic
reconstruction following the resection of genital elephantiasis tissue. A pedicled SCIP lymphatic flap is
transferred to reconstruct the scrotum and bridge the lymphatic pathways in one procedure. The LIFT
component in RRR is critical in curbing the risk of early postoperative complications such as high output
exudate, wound dehiscence, infection, and lymphedema recurrence . This is because lymphedematous
[16]
tissue is often inadvertently left behind even after radical resection is performed.