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Page 4 of 11 Seki et al. Plast Aesthet Res 2021;8:58 https://dx.doi.org/10.20517/2347-9264.2021.80

Figure 1. Mechanism of the dynamic LVA method. The dynamic LVA method is based on the patient’s natural hand movements in daily
life. At the incision point, which is detected by preoperative dynamic US findings, the patient’s natural hand motions propel lymphatic
fluid into the anastomosed vein instead of the degenerated lymphatic vessels’ smooth muscle power. Negative pressure in the large
pumping vein (> 1.0 mm) in the diastolic phase draws lymphatic fluid via LVA. The original source of this figure is from Ref. [20] with
permission for reuse. LVA: Lymphaticovenular anastomosis; US: ultrasonography.

pumped with the muscle movements in dynamic US, the point is defined as the incision. The pumping
subcutaneous vein has negative pressure in the lumen when this vein is opening in cooperation with muscle
pumping [21,23] . Because LVA is created using the small subcutaneous vein that is the first to third branch of
the large pumping vein (> 1.0 mm) at the incision, lymphatic fluid is drawn from the lymphatic vessel to the
anastomosed vein of LVA by the power of negative pressure created by the large pumping subcutaneous
vein (> 1.0 mm) [Figure 1]. The dynamic US findings of the pumping vein with movements of the blood at
the lymphedematous arm are depicted in Supplementary Video 1. The other details of ultrasonographic
findings of the dynamic LVA method are described in our previous paper with the video of dynamic US .
[21]

The clinical significance of the dynamic LVA method is very early improvement of lymphedema, even often
seen intraoperatively as decreased stiffness and volume reduction around the site of LVAs. In addition,
intraoperative hand movements can enhance flow of lymphatic fluid to the anastomosed vein, and the
confirmation of the patency of the anastomosis can become more precise. The effect of intraoperative hand
movement in the dynamic LVA method is depicted in Supplementary Video 2.

The superior-edge-of-the-knee incision method for lower extremity lymphedema
The strategy of creating functional LVA differs between patients with UEL and those with LEL . In UEL,
[23]
selecting the muscle pumping point as an incision especially where the pumping vein exists is important,
because the hand movements even created by small muscle have enough power to propel lymphatic fluid
into the anastomosed vein of LVA.