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

up the back wall. This technique is beneficial when the lymphatic vessels are not sclerosed severely.

Supermicrosurgical LVA style 2: expanding technique [Supplementary Video 2]
The first suture is performed using the one-hand suture technique. In this LVA style, the second suture is
placed at the opposite side of the first suture. With this technique, the one side tip of the forceps is difficult
to insert into the vessels to check the lumen. However, this suture style makes it possible for microsurgeons
to feel the lumen more precisely using the one-side suture technique even when the lymphatic vessels are
severely sclerosed. After the second suture, even the weak lymphatic flow of sclerosed lymphatic vessels
dilatate the anastomosing vessels. In severe lymphedema patients, lymphatic fluid with high viscosity rarely
leaks out from the small vessels’ gap even when under only two sutures have been built. In this situation,
microsurgeons can feel the expanded lumen of the vessel to make additional sutures. Two to three
additional sutures are easily added between both arc sides of the first two stitches.

Techniques in LVA STEP 4: closing the incision with wound bed preparation for LVA
[Supplementary Video 3]
Before closing the wound, it is considered that making a comfortable wound bed for LVA is important, not
only to keep longtime patency of the anastomosis but also to increase lymphatic flow at the anastomosis.
After the fixations of the incision are all released, both sides of the incision are carefully pulled upward. If
fibers in the subcutaneous tissues and/or the other lymphatic vessels are three-dimensionally disturbing the
created LVA, these structures should be resected [Figure 5]. Because the LVA incision is small in size and
lymphatic vessels have collaterals in the extremities, it is more beneficial to cut the disturbing small vessels
to increase the lymph-to-venous flow at the LVA for lymphedema improvement. These fibers and/or vessels
never play an important role in the lymphatic circulation for patients’ lymphedema because they already
reveal severe lymphedema before cutting these fibers and/or vessels. Supplementary Video 3 depicts the
senior author’s technical tricks and tips for LVA including how to make LVA using relatively large vessels,
how to check the intraoperative patency of LVA, and how to make a comfortable wound bed for LVA.

SUPERMICROSURGICAL LVA IN THE FUTURE
The clinical advantage of LVA is the immediate and long-term effect for peripheral lymphedema. In
addition, the clinical effects of LVA for generated and acquired lymphatic dysplasia in neonates and infants
with pleural effusion, chylothorax, or ascites are reported as a novel surgical treatment for life-threating
disorders [24-26] . LVA has the possibility to become a first-line surgical treatment for lymphatic diseases in the
future because LVA is a minimal invasive surgical treatment with few complications. Furthermore, LVA has
pathological advantages that can be easily added to future treatment using lymphangiogenesis technology
and regenerative medicine as a combination therapy.

The disadvantage of LVA is the technically difficulty of fine procedures, although technological
advancements in operating microscopes including robotic microsurgery are considered to make it possible
to perform LVA more easily in the future. Even in this situation, microsurgeons’ finger sensation to feel the
lymphatic fluid and the lumen must be important to create more and more accurate anastomoses.

The authors believe that most microsurgeons can perform LVA with knowledge of Isao Koshima’s
supermicrosurgery.

CONCLUSIONS
LVA is highly effective, minimally invasive surgical treatment for lymphedema. Fundamental and essential
techniques for supermicrosurgery facilitate LVA by decreasing risk of postoperative LVA occlusion.