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Seki et al. Plast Aesthet Res 2021;8:58 https://dx.doi.org/10.20517/2347-9264.2021.80 Page 9 of 11

Figure 5. Continuous effect of the superior-edge-of-the-knee incision method. A 71-year-old woman had suffered bilateral lower
extremity lymphedema (LEL) for 7.8 years following hysterectomy. This patient is the same patient as reported in Ref. [21] . The LEL index
at her right leg was 276.3 preoperatively. Lymphaticovenular anastomosis including the superior-edge-of-the-knee-incision method was
performed on her right leg. Her lymphedema symptoms improved continuously and gradually with improvement of right LEL index,
which was reduced to 257.1 at 14 months, 221.7 at 3 years, and 210.2 at 4 years. In addition, preoperative ICG lymphography severity of
wide stardust areas was improved postoperatively at four years. The original source of this figure is from Ref. [21] with permission for
reuse.

DECLARATIONS
Acknowledgments
The authors thanks Isao Koshima for sharing his knowledge, surgical techniques, passion, and zeal for
lymphedema treatment. This article is reported with all our respect of the father of supermicrosurgery, Isao
Koshima. And the senior author thanks Yoshiharu, Miyuki, Hanano, Mayoko, and all members of our
department for their kind support during preparation of this manuscript.

Authors’ contributions
Preparation of the article, and study design: Seki Y
Data analysis: Seki Y, Asai R
Performed data acquisition, as well as provided administrative, technical, and material support: Kajikawa A,
Asai R, Takada T, Takumi Y, Terashima T, Kurogi N

Availability of data and materials
Not applicable.

Financial support and sponsorship
JSPS KAKENHI Grant Number JP17K17038 (to Seki Y).

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
This study was conducted under approval from the St. Marianna University School of Medicine ethics
committee (Approval number: 4768).