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Page 2 of 8 Hosomi et al. Plast Aesthet Res 2023;10:60 https://dx.doi.org/10.20517/2347-9264.2023.77

INTRODUCTION
The first lymphaticovenular anastomosis (LVA) was reported by Yamada in 1969 . However, the practical
[1]
utilization of LVAs in the treatment of lymphedema remained limited until the development of
supermicrosurgical technique that enabled anastomosis of vessels less than 0.5 mm in diameter and the
[2]
establishment of supermicrosurgical LVA by Koshima in 2000 . The surgical treatment for lymphedema
has since evolved, with LVA, VLNT, and vascularized lymphatic transplantation (LT) becoming the
common methods used for treatment .
[3-5]
LVA is especially effective for early stages of lymphedema but is less effective for severe cases in which the
lymphatics have already become sclerotic . In such severe cases of lymphedema, VLNT or LT are often
[3,6]
[4,6]
required . VLNT was first reported by Chen et al. in the canine model in 1990 and has become the major
surgical treatment for severe lymphedema of the extremities . The outcome of VLNT in extremity
[7,8]
lymphedema showed significantly better improvement in the long term compared to LVA, although both
procedures were effective in the short term . A recent review reported that mild or moderate lymphedema
[9]
of extremities who undergo VLNT are more likely to avoid the need for postoperative further conservative
[10]
therapy, but severe lymphedema extremities still require conservative therapy after VLNT . The concept
behind conventional VLNT is that lymphatic fluid is absorbed by the lymph node and then flows out to the
recipient vein [7,11] . The disadvantage of this procedure is that there is no effective utilization of the original
efferent lymphatic vessel, and this may cause subsequent efferent lymphatic channel obstruction following
lymph node sclerosis.

LT was first reported by Koshima in 2016 to transfer vascularized lymphatic vessels to treat lymphedema in
tissues with irreversible lymphatic smooth muscle cell degeneration . However, this method also does not
[3]
include anastomosis of lymphatic vessels.

In order to reconstruct the physiological and natural lymphatic flow, reconstruction of lymphatic bypass
from the affected areas to intact lymphatics using transplanted vascularized lymphatic tissue with the
restoration of efferent lymphatic flow is ideal. In this case report, we present the first case of reconstruction
of lymphatic flow using vascularized lymph nodes and lymphatics with efferent channel anastomosis in a
patient with upper extremity lymphedema.

CASE REPORT
A 63-year-old female presented with a history of progressively worsening right upper extremity
lymphedema. Fourteen years ago, she underwent a right partial mastectomy and axillary lymph node
dissection for right breast cancer. A diagnosis of secondary lymphedema was made at her local hospital 11
years postoperatively, and conservative therapy using the compression sleeves commenced following this
diagnosis. Although she continued to apply this therapy for 2 years, the right upper extremity lymphedema
had worsened. She was referred to our department for surgical consideration 13 years postoperatively.

On arrival, a physical examination revealed that her right upper extremity lymphedema (UEL) was classified
stage II according to the International Society of Lymphology (ISL) classification. The UEL index of her
right extremity was 141 and classified as stage II according to the UEL stage . The UEL index was
[12]
calculated as described by Yamamoto et al. by a summation of squares of limb circumferences (cm) at five
points (the elbow, five cm above and below the elbow, the wrist, and the dorsum of the hand) divided by
body mass index . The UEL stage is as follows: < 130 corresponded to UEL stage I, 130 to 150
[12]
corresponded to UEL stage II, 150 to 170 corresponded to UEL stage III, and < 170 corresponded to UEL
stage IV. Preoperative indocyanine green (ICG) lymphography showed dermal backflow of stardust pattern