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Page 6 of 11 Seki et al. Plast Aesthet Res 2021;8:58 https://dx.doi.org/10.20517/2347-9264.2021.80

relatively large in diameter with less degeneration.

As preparation of the method, the incision site is identified as the intersection of a transverse line drawn at
the superior edge of the patella and a longitudinal line drawn along the medial axis of the distal thigh with
the patient in the supine position. From the point of intersection, a 2.5 cm transverse incision is made
posteriorly [Figure 3]. The incision site can be set without any imaging study because the lymphatic vessel
for functional LVA is always detected at this point in all patients.

At the incision point, many lymphatic vessels can be identified over and under the superficial fascia in
subcutaneous tissue [21,22] . Lymphatic vessels under the superficial fascia should be selected for LVA in this
method because strong upward propulsion of lymphatic fluid to the anastomosed vein is created by the
gracilis muscle pumping, which compress soft tissues between the deep fascia and the superficial fascia that
cooperate in knee joint movement. Before dissection under the superficial fascia, the subcutaneous vein
with good valvar function is detected and dissected for LVA over the subcutaneous fascia at this point.

To obtain a lymphatic vessel residing in rich fatty tissue under the superficial fascia, 3-0 nylon
monofilament is used to catch the lymphatic vessel. The lymphatic vessel is then dissected from rich fatty
tissue up to 1.5 cm proximally, supported by careful traction of the vessel with the 3-0 nylon monofilament.
The lymphatic vessel is carefully cut with microscissors at the most proximal point of dissection. The vessel
is pulled out over the superficial fascia to be anastomosed with the subcutaneous vein with good valvar
function there.

Because relatively large and less degenerated lymphatic vessels can be detected at the incision, the lymphatic
vessel can be anastomosed to the subcutaneous vein with 11-0 nylon suture without using 12-0 nylon
suture. The procedure of the superior-edge-of-the-knee incision method is depicted in Supplementary
Video 3.

OUTCOMES
The functional LVA for UEL, i.e., the dynamic LVA method, was reported in a case-control study of 30
patients . All patients were under sleeve compression. The 30 International Society of Lymphology (ISL)
[20]
stage 2 UEL patients were divided into two groups: 15 patients were treated by means of three traditional
LVAs via three incisions without preoperative dynamic US, while 15 were treated by means of three
dynamic LVAs via three incisions. The characteristics of the patients per group are shown in Table 1, and
there was no significant difference between the two groups. Postoperative volume reduction in UEL index at
1 month, 6 months, and one year were compared between the two groups [Table 2]. The dynamic LVA
group patients revealed very early improvement of decreased stiffness and volume reduction before
restarting compression therapy. Although the conventional LVA group patients had some recurrence of
edema after the LVA, the dynamic LVA group patients revealed no recurrence of edema after the surgery.
The rates of finishing compression therapy at two years postoperative were significantly greater in the
dynamic LVA group than in the conventional LVA group [12 of 15 follow-up patients (80.0%) vs. 5 of 13
follow-up patients (38.5%); P = 0.023] [Figure 4].
[28]
The functional LVA for LEL, i.e., the superior-edge-of-the-knee incision LVA, was first reported in a case-
[21]
control study of 30 patients . All patients were under compression stockings. The 30 ISL stage 2 LEL
patients were divided in two groups. Fifteen patients were treated by traditional multiple LVAs without the
superior-edge-of-the-knee incision method, while the other 15 were treated by multiple LVAs including the
superior-edge-of-the-knee incision method. Large lymphatic vessels (≥ 0.65 mm) were detected significantly