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Page 2 of 11 Seki et al. Plast Aesthet Res 2021;8:44 https://dx.doi.org/10.20517/2347-9264.2021.74

INTRODUCTION
Lymphedema is a chronic and progressive disease which causes physical and psychological morbidity in
[1-4]
upper and lower extremities . Lymphaticovenular anastomosis (LVA) is a highly effective, minimally
invasive surgical treatment for lymphedema [5-14] , in which a new lymphatic pathway is created by
anastomosing the peripheral lymphatic vessel directly into the subcutaneous vein. The surgical effect of
LVA appears immediately after the surgery, because of physiological changes of lymph dynamics in the
affected limbs [9-12] .

The clinical effect of LVA usually continues for a longtime. However, LVA is under the risk of future
occlusions [15,16] . That is why the long-term outcome of LVA is not always guaranteed. There are many
potential risks of postoperative LVA occlusion, which include lymphatic vessels’ degenerations,
lymphedema severity, postoperative managements, surgical site infection, patients’ compliance, selection of
LVA location, changes of postoperative lymphatic dynamics, and surgical procedures themselves [8-18] .
Among these reasons for LVA occlusions, selection of LVA locations and fine procedures in LVA are
particularly important for microsurgeons to achieve good clinical results [7-14] .

Because surgical skills of LVA require one of the finest techniques in microsurgery, only minor mistakes
could result in LVA failure. Depending on the type of unsuitable LVA procedures, there is a risk of LVA
occlusion in early, mid-, or late-postoperative course. Inaccuracy of the anastomosis and structural
disturbance between the lymphatic vessel and the subcutaneous vein are potential risks for early- or mid-
postoperative occlusion of LVA. In contrast, instability of decreased lymphatic flow at the anastomosis,
which is induced by improvement of lymphedema, is considered to cause mid- or late-postoperative LVA
occlusion. Although there are many reasons for LVA occlusions, technically indued LVA occlusions are
considered to be avoidable with the development of fine procedures.

In this paper, the fundamental and essential techniques to perform supermicrosurgical LVA are described
to improve accuracy of intraoperative procedures with the basic theory of Isao Koshima’s
supermicrosurgical LVA. In addition, the senior author’s current techniques in LVA procedures which have
been explored to improve the therapeutic effect of LVA based on Isao Koshima’s teachings are described
with video files (see the Supplementary Materials).

FUNDAMENTAL TECHNIQUES IN SUPERMICROSURGERY
The concept of supermicrosurgery has been advocated by Isao Koshima since the 1990s to anastomose small
vessels less than 0.80 mm in diameter using operating microscopes [19,20] . Because recent advancements in
operating microscopes and surgical instruments make anastomosis of small vessels relatively easy, the true
supermicrosurgical techniques are mostly applied to anastomose small vessels less than 0.50 mm in
diameter for lymphatic surgery, fingertip replantation, nerve flap, and perforator-to-perforator tissue
transplantation nowadays [8-14,20] .

Supermicrosurgery is sometimes misunderstood just as special techniques to handle small vessels with
operating microscopes at high magnification. However, the true concept of supermicrosurgery is based on
skills to feel the intima of vessels or lymphatic flow itself by microsurgeons’ finger sensation via the tip of
the needle to perform intima-to-intima anastomosis between very small vessels.

These finger sensation skills make it possible to anastomose small vessels using a normal operating
microscope with normal magnification function: the senior author usually selects 12-18 times magnification
of operating microscope to anastomose vessels over 0.25 mm in diameter [10-12] . When this finger sensation