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Page 4 of 11 Seki et al. Plast Aesthet Res 2021;8:44 https://dx.doi.org/10.20517/2347-9264.2021.74

Figure 1. Safe procedure in traditional (non-supermicrosurgery) microsurgery. In traditional microsurgery (non-supermicrosurgery), the
left hand is used to insert the tips of forceps into the anastomosing vessel to dilate and keep the lumen. Intima-to-intima anastomosis
can be performed in each suture by inserting the left-hand forceps into the lumen to not pick up the back wall.

Figure 2. The left-hand forceps in supermicrosurgery to perform intima-to-intima anastomosis. In handling small vessels less than
0.5 mm in diameter, only one side tip of the forceps can be inserted and dilate the lumen. In supermicrosurgery, the surgeon’s left hand
always holds the last suture or the adventitia of the lymphatic vessel and vein when making suture to feel the intima of vessels and
lymphatic flow itself. In addition, the right hand plays an important role to feel the lumen of the anastomosing vessel, cooperating with
the left hand’s feeling by sensing the tip of the needle via the needle holder.

Furthermore, severe lymphedema patients reveal degeneration of lymphatic vessels [8,17,18] . Degenerated
lymphatic vessels are fragile and easily rupture even under fine procedures of microsurgical dissection.
More delicate procedures are required in severe lymphedema because the lumen of degenerated lymphatic
vessels become very narrow, and the sclerosed endometrium is easily peeled off. In this situation, skills to
feel the flow of lymph and the adequate tensioned left-hand traction are necessary to perform anastomosis
while searching for the true lumen from the easily peeled intima of the sclerosed lymphatic vessel [Figure 3].

After the LVA creation, it is necessary to remove any factors which can block or disturb the flow of lymph
in LVA before closing the wound.

Techniques in LVA STEP 1: incision and fixation of the surgical site
Based on Isao Koshima’s supermicrosurgical theory, the senior author’s current step-by-step LVA
procedures are described as follows.