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Onishi et al. Plast Aesthet Res 2021;8:50 https://dx.doi.org/10.20517/2347-9264.2021.75 Page 7 of 9

and the eventual thrombosis due to venous reflux. Similarly, several clinical studies have reported that
[22]
venous reflux diminished the surgical outcome with LVA and caused occlusion of the anastomotic site
[23]
over time .
[21]
Tourani et al. mentioned possible technical ideas to overcome the decrease in lymphatic pressure and
thrombus formation from venous reflux at the anastomoses; however, they did not include a
physiotherapeutic approach. In other words, muscle pumping under compression therapy can amplify
lymphatic flow [20,24,25] . Chen et al. observed that immediate limb compression following LVA prevented
[26]
[25]
venous backflow by augmenting lymphatic pressure. Likewise, according to Olszewski et al. , muscle
contraction in the lower leg increased lymphatic pressure and could play an important role as a driving
force for lymph flow. They observed that lymphatic pressure could rise as much as 100 mmHg during
muscle contraction under compression therapy and that the optimal compression pressure was 40 mmHg.
It can be hypothesized that this amplified lymphatic flow yielded by muscle pumping under compression
therapy could boost bypass flow and overcome venous reflux. Thus, we presumed that LVA followed by
reduction treatment in the early postoperative period would be more beneficial than LVA with maintenance
treatment resumed after a certain period of interruption.

Generally, LVA is indicated when conservative therapy is proven to be insufficient or plateaued [12,13] . Studies
have reported that the previous compression therapy, namely maintenance treatment, should be restarted
one month postoperatively [7,9,10,27] . We believe that this may be a loss of great opportunity for another
reduction treatment because the lymphatic-venous pressure gradient and the boosted lymphatic function
could be optimal in the early postoperative period with the bypasses. Our findings support the possibility of
improving lymphedema more efficiently by combining PORT with LVA. We aimed at the highest interface
pressure the patient could tolerate by exerting 20-60 mmHg using compression therapy, as reported in
previous studies [1,25] . Additionally, we demonstrated that physical exercise under compression could be
combined efficiently and safely as an integral part of PORT. Without a doubt, patients should continue
maintenance treatment at home after discharge from the hospital to maintain the reduction in edema.

As previous studies have reported low rates of complications for LVA surgery, such as infection and
[27]
lymphorrhea , our clinical protocol was not accompanied by those complications perioperatively.
Undoubtedly, care must be taken to avoid shear stress on the anastomotic site when patients apply
[28]
compression garments or bandages in the early postoperative period. In addition, remedial exercise is not
considered harmful for anastomotic sites unless they are exposed to a traumatic external force. Several
review studies have shown that the hospital stay after LVA surgery can be as short as 1 day , and patients
[29]
are assumed to return to their normal daily life. It is presumed that our exercise protocol activity during
hospital stay is no more than daily activities. Thus, our study may support the safety of reduction treatment
in the early postoperative period.

Our study has some limitations. First, we cannot separately determine the exact efficacy of LVA and that of
perioperative reduction treatment because edema reduction after LVA should be an integrated effect of both
LVA and CDT. Therefore, further investigation should clarify whether our enhanced treatment efficacy can
be attributed to the effect of LVA itself under augmentation with PORT or the effect simply added by CDT.
Second, we did not address the long-term patency of LVA. Accordingly, whether perioperative reduction
therapy can impact the patency of LVA should be elucidated in future studies. Third, our assessment only
focused on the edema reducing effect with the suggested lymphedema treatment. Since lymphedema is
often comorbid with acute or chronic inflammation as well as fluid accumulation, further investigation
regarding the efficacy of the suggested combined treatment on reducing inflammation is needed.