RECONSTRUCTIVE

Lymph Flow Restoration after Tissue

Replantation and Transfer: Importance of
Lymph Axiality and Possibility of Lymph Flow
Reconstruction without Lymph Node Transfer
or Lymphatic Anastomosis
Takumi Yamamoto, M.D.,
Ph.D.
Takuya Iida, M.D., Ph.D.
Hidehiko Yoshimatsu, M.D.
Yuma Fuse, M.D.
Akitatsu Hayashi, M.D.
Nana Yamamoto, M.D.
Tokyo and Chiba, Japan
Background: The lymph system plays important roles in maintaining fluid bal-
ances, the immune system, and lipid metabolism. After tissue replantation or
transfer, some cases suffer long-lasting edema or lymphedema caused by inter-
ruption of main lymph flows; however, this mechanism has yet to be clarified.
Methods: The medical charts of 38 patients who underwent indocyanine green
lymphography after tissue replantation or free flap transfer were reviewed to
obtain data regarding clinical demographics, intraoperative findings, and post-
operative indocyanine green lymphographic findings. Postoperative lymph flow
restoration based on indocyanine green lymphographic findings was evaluated
according to intraoperative findings, including raw surface in lymph axiality
and compatible lymph axiality.
Results: Lymph flow restoration was observed in 24 cases (63 percent). There
were significant differences in positive lymph flow restoration with regard to
sex (male, 78 percent; female, 40 percent; p = 0.017), cause of defect (trauma,
83 percent; others, 33 percent; p = 0.002), type of operation (replantation, 94
percent; free flap, 41 percent; p = 0.001), and compatible lymph axiality (posi-
tive, 96 percent; negative, 0 percent; p < 0.001). Based on lymph axiality, the
raw surface in lymph axiality–negative and compatible lymph axiality–positive
condition was completely matched with lymph flow restoration positivity; 100
percent accuracy to predict postoperative lymph flow restoration was observed.
Conclusions: Lymph flow can be restored after tissue replantation or free flap
transfer without lymph node or supermicrosurgical lymphatic anastomosis.
The raw surface in lymph axiality–negative and compatible lymph axiality–
positive condition is considered a key for restoring lymph flows after surgery
affecting the main lymph pathway. (Plast. Reconstr. Surg. 142: 796, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

T
he lymph system is an important homeosta-
sis system for maintaining fluid balances, the
immune system, and lipid metabolism.1–3
Lymph flow obstruction, caused by cancer ablative
From the Department of Plastic and Reconstructive Surgery,
Center Hospital of National Center for Global Health and
Medicine; the Department of Plastic and Reconstructive Sur-
gery, the University of Tokyo Hospital; the Department of
Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital; and
the Department of Plastic Surgery, Asahi General Hospital.
Received for publication July 29, 2017; accepted March 8,
2018.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004694
surgery/radiation therapy, trauma, malforma-
tion, or inflammation results in localized immu-
nologic insufficiency, abnormal lipid profiles, and
excess lymph in the interstitial space manifested
as lymphedema.2–5 Major trauma or wide resec-
tion for malignant tumor in the extremities often
involves dominant lymph pathways along the
large subcutaneous veins such as the saphenous
vein and the cephalic veins, which may cause per-
manent lymph flow obstruction and subsequent
chronic lymphedema.6–9 Lymphedema affects
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

796 www.PRSJournal.com
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 Volume 142, Number 3 • Lymph Flow Restoration
postoperative rehabilitation and the patient’s
quality of life because of prolonged edematous
conditions and inflammation.
Lymphatic channels can usually restore lymph
pathways and functions by lymphangiogenesis
after anatomical destruction such as surgery or
trauma, but some cases manifest chronic lymph-
edema.6–12 Although there are a few studies regard-
ing lymph flow evaluation using lymph imaging
modalities, it is unclear what factors affect lymph
flow restoration after trauma or surgery involving
major lymph pathways.6,11,12 With advancement
of near-infrared fluorescent lymphography using
indocyanine green, precise evaluation of superfi-
cial lymph flow becomes possible.13–22 We aimed
to investigate factors associated with lymph flow
restoration after tissue replantation and transfer
by evaluation of superficial lymph flow using indo-
cyanine green lymphography.
PATIENTS AND METHODS
Medical charts of 38 consecutive patients
who underwent indocyanine green lymphogra-
phy after tissue replantation or free flap trans-
fer from July of 2011 to December of 2016 were
reviewed to evaluate the relationship between
postoperative lymph circulation and intraopera-
tive findings. Sixteen patients underwent tissue
replantation and 22 patients underwent free flap
reconstruction. Clinical charts were reviewed to
collect clinical findings and indocyanine green
lymphographic findings.
In tissue replantation cases, replantation oper-
ations were performed in a conventional way as
reported previously.23,24 In 15 of the 22 free flap
transfer cases, flap surgery was performed in a
conventional way without indocyanine green lym-
phographic guidance. In the remaining seven
free flap cases, indocyanine green lymphography
was performed preoperatively to map superficial
lymph flows in both donor and recipient sites,
and the linear pattern was marked on the skin as
reported previously; 0.2 ml of indocyanine green
(Diagnogreen 0.25%; Daiichi Pharmaceutical,
Tokyo, Japan) was injected subcutaneously 10 to
15 cm distally to donor and recipient sites.14,15,25
After indocyanine green injection, circumfer-
ential fluorescent images of lymphatic drain-
age channels were obtained using an infrared
camera system (Photodynamic Eye; Hamamatsu
Photonics K.K., Hamamatsu, Japan).21,22 Indocya-
nine green lymphographic images were recorded
immediately after indocyanine green injection to
mark the linear pattern. In flap inset, edges of the
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
linear pattern on a flap skin island and those on
recipient skin were approximated as close as pos-
sible under intraoperative indocyanine green lym-
phographic navigation; 3-0 Vicryl (Ethicon, Inc.,
Somerville, N.J.) subdermal sutures were placed
without supermicrosurgical lymphatic anastomo-
sis. Lymph node was not involved in any flaps in
this cohort.
Postoperative indocyanine green lymphogra-
phy was performed 3 months after replantation or
free flap surgery. In replantation cases, 0.1 ml of
indocyanine green was injected at the most distal
site of the replanted tissue. In flap transfer cases,
0.1 ml of indocyanine green was injected into
the digital tip when a flap was transferred to the
hand, digit, or foot. When a flap was transferred
to a more proximal region, 0.2 ml of indocya-
nine green was injected 10 to 15 cm distally to the
recipient site. After indocyanine green injection,
circumferential fluorescent images of lymph flow
were obtained using an infrared camera system.
On postoperative indocyanine green lym-
phography, restoration of lymph flow continu-
ity between amputee/flap and recipient site was
evaluated; when the linear pattern was observed
in both the amputee/flap and the recipient site
continuously, lymph flow restoration was evalu-
ated as positive; when the linear pattern was not
observed in the amputee/flap because of an
extensive dermal backflow pattern such as splash,
stardust, or diffuse pattern, lymph flow restoration
was evaluated as negative (Fig. 1).14 Postoperative
indocyanine green lymphographic findings were
evaluated according to patient characteristics and
intraoperative findings, including age, sex, type
of operation, raw surface in lymph axiality, and
compatible lymph axiality. When there was a 2-cm-
wide or wider raw surface area between lymphatic
vessel stumps of an amputee/flap and a recipient
site, raw surface in lymph axiality was evaluated
as positive. When lymph flow directions of an
amputee/flap and a recipient site were matched,
compatible lymph axiality was evaluated as posi-
tive; when there was a distance shorter than 2 cm
between lymphatic vessels stumps of an amputee/
flap and a recipient site, compatible lymph axial-
ity was evaluated as positive.
Statistical analyses were performed using the
Mann-Whitney U test for continuous variables and
the chi-square and Fisher’s exact probability test
for categorical variables; Fisher’s exact provability
test was used when any of expected values were
below 5. Statistical significance was defined as a
value of p < 0.05. This retrospective observational
study was approved by the institution’s ethical
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 Plastic and Reconstructive Surgery • September 2018

Fig. 1. Indocyanine green lymphographic findings are classified into normal

linear pattern, and abnormal dermal backflow (DB) pattern. The dermal back-
flow pattern is subdivided into slash, stardust, and diffuse patterns.

review board, and all patients gave written con-
sent to participate this study.
RESULTS
Patient age ranged from 22 to 70 years
(median, 42 years), and 23 patients were men (60
percent). Cause of defect was acute trauma in 23
cases (60 percent). Twenty-seven patients (71 per-
cent) underwent surgery on the upper extremity,
and the remaining 11 (29 percent) underwent sur-
gery on the lower extremity or the penis. In tumor
resection cases, no patient underwent lymph node
dissection or perioperative adjuvant therapy in this
study cohort. Indocyanine green lymphographic
guidance was used in seven cases of free flap
transfer, among which compatible lymph axiality
could be achieved in five cases, with a significantly
higher compatible lymph axiality–positive rate
than those without indocyanine green lympho-
graphic guidance (indocyanine green lymphog-
raphy guidance–positive, 71 percent; indocyanine
green lymphography guidance–negative, 27 per-
cent; p = 0.047); two of seven indocyanine green
lymphography-guided cases could not achieve
compatible lymph axiality, because lymphatic ves-
sel stumps could not be approximated when flaps
were inset to cover the defects. Raw surface in
lymph axiality was seen in two cases (5 percent),
and compatible lymph axiality was seen in 25
cases (66 percent). On postoperative indocyanine
green lymphography, lymph flow restoration was
observed in 24 cases (63 percent) (Tables 1 and 2).
Several factors were found to be associ-
ated with postoperative lymph flow restoration
(Table 3). There were significant differences in
positivity for lymph flow restoration with regard
to sex (male, 78 percent; female, 40 percent;
p = 0.017), cause of defect (trauma, 83 percent;
others, 33 percent; p = 0.002), type of operation
(replantation, 94 percent; free flap, 41 percent;
p = 0.001), and compatible lymph axiality (posi-
tive, 96 percent; negative, 0 percent; p < 0.001).
Based on lymph axiality, the “raw surface in lymph
axiality–negative and compatible lymph axiality–
positive” condition was completely matched with
positivity for lymph flow restoration; 100 percent
accuracy to predict postoperative lymph flow res-
toration was achieved (Table 4). Representative
cases are shown in Figures 2 through 6.
DISCUSSION
This study revealed that lymph flows could
be restored after tissue replantation or free flap
transfer without supermicrosurgical lymphatic
vessel anastomosis or lymph node transfer.
Lymph flow seemed to be restored by connection
between lymphatic vessels that originally existed
in an amputee/flap and a recipient site, not by
development of new lymph pathways. In replan-
tation cases, lymph flow restoration was observed
except for one case with raw surface in lymph
axiality. Because lymph axiality between amputee
and recipient site is usually matched in replanta-
tion cases, only scar formation attributable to raw
surface area seems to interrupt lymph flow resto-
ration by means of lymphangiogenesis.23,24 Among
free flap transfer cases, lymph flow restoration was
observed only in cases with compatible lymph axi-
ality. When there is no compatible lymph axiality,
lymphangiogenesis is considered insufficient to
connect distant lymphatic vessels between a recip-
ient site and a flap. As shown in Table 4, lymph

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 142, Number 3 • Lymph Flow Restoration

Table 1. Operation Summary of Replantation Cases

Defect Operation Results
Patient Age Sex Cause Site Level RLA* CLA† LFR‡
1 45 F Crush amputation Thumb Zone 2§ − + +
2 61 F Crush amputation Middle finger Zone 2§ − + +
3 28 M Crush amputation Middle finger Zone 4§ − + +
4 38 M Clean amputation Penis Middle part of the penis − + +
5 42 F Crush amputation Little finger Proximal phalanx +║ + −
6 42 M Crush amputation Thumb Zone 2§ − + +
7 32 M Crush amputation Index finger Proximal phalanx − + +
8 35 M Crush amputation Index finger Proximal phalanx − + +
9 45 M Crush amputation Index finger Zone 2§ − + +
10 38 M Crush amputation Little finger Zone 2§ − + +
11 66 M Crush amputation Ring finger Zone 3§ − + +
12 29 M Crush amputation Thumb Zone 2§ − + +
13 26 M Crush amputation Index finger Zone 2§ − + +
14 22 M Crush amputation Middle finger Zone 2§ − + +
15 31 M Crush amputation Ring finger Zone 2§ − + +
16 23 M Crush amputation Ring finger Zone 2§ − + +
RLA, raw surface in lymph axiality; CLA, compatible lymph axiality; LFR, lymph flow restoration; F, female; M, male; ICG, indocyanine green.
*Existence of raw surface area in main lymph flows.
†Compatible lymph axiality between amputee and recipient site.
‡LFR between an amputee and a recipient site based on postoperative ICG lymphography.
§Tamai classification for amputation level.
║A 2-cm-wide raw surface remained.

Table 2. Operation Summary of Free Flap Transfer Cases

Defect Operation Results
Age
Patient (yr) Sex Cause Site Size (cm) Flap ICG* RLA† CLA‡ LFR§
1 69 M Crush amputation Thumb 5×3 HP − − + +
2 59 F Crush amputation Thumb 6×4 WA − − + +
3 37 M Crush amputation Index finger 5×3 HP − − + +
4 44 M Burn contracture Upper arm 18 × 7 TAP − − − −
5 54 M Degloving injury Ring finger 12 × 6 SIEA − − − −
6 44 F AVM Lower leg 20 × 7 TAP − − − −
7 27 F AVM Little finger 14 × 6 TAP − − − −
8 60 F AVM Thumb 7×5 WA − − + +
9 70 F Sarcoma Upper arm 16 × 14 SCIP − − − −
10 53 F AVM Foot 22 × 7 TAP − − − −
11 64 F Burn contracture Knee 30 × 10 DIEP − − − −
12 63 F Ulcer║ Lower leg 32 × 8 TAP − +¶ − −
13 35 M Scar contracture Elbow 30 × 10 TAP − − − −
14 50 M AVM Hand 20 × 10 TAP − − − −
15 34 F Sarcoma Forearm 20 × 7 ALT − − − −
16 57 M Ulcer Ankle 14 × 6 SCIP + − + +
17 32 M Carcinoma Forearm 14 × 7 SCIP + − − −
18 54 F Sarcoma Lower leg 34 × 18 TRAM + − + +
19 30 F Ulcer║ Lower leg 14 × 7 SCIP + − − −
20 48 F Burn Ankle 12 × 6 SCIP + − + +
21 36 M Ulcer Knee 23 × 10 DIEP + − + +
22 42 M Ulcer Lower leg 16 × 7 TAP + − + +
ICG, indocyanine green; RLA, raw surface in lymph axiality; CLA, compatible lymph axiality; LFR, lymph flow restoration; M, male; F, female;
HP, hemi-pulp; WA, wraparound; TAP, thoracodorsal artery perforator; SIEA, superficial inferior epigastric artery; AVM, arteriovenous mal-
formation; SCIP, superficial circumflex iliac artery; DIEP, deep inferior epigastric artery; ALT, anterolateral thigh; TRAM, transverse rectus
abdominis myocutaneous.
*Preoperative ICG lymphographic guidance to conform lymph axiality between flap and recipient site.
†Existence of raw-surface area in main lymph flows.
‡Compatible lymph axiality between flap and recipient site.
§LFR between a flap and a recipient site based on postoperative ICG lymphography.
║Intractable ulcer following trauma.
¶A 3 cm-wide raw surface remained.

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 Plastic and Reconstructive Surgery • September 2018

Table 3. Analysis of Factors Associated with less likely to occur. Because previous studies sug-
Postoperative Lymph Circulation gested that lymphangiogenesis may occur after
LFR- LFR-
wound healing with width of few centimeters, we
Negative* Positive* used 2-cm as a cutoff value of raw surface in lymph
(%) (%) p axiality and compatible lymph axiality.1,8,12,13,15,19 It
No. 14 24 is noteworthy that lymph node is not necessary
Age, yr 0.490 to restore lymph flows when proximal and dis-
 Median 37 49 tal ends of lymphatic vessels in a defect can be
 Range 22–66 27–70
Sex 0.017† bridged using lymphatic vessels included in a flap.
 Male 5 (22) 18 (78) In replantation cases and toe transfer cases,
 Female 9 (60) 6 (40) compatible lymph axiality can be relatively eas-
Cause 0.002†
 Trauma‡ 4 (17) 19 (83) ily achieved, because lymphatic vessels are known
 Others§ 10 (67) 5 (33) to exist in the midlateral aspect of the digits.15,26–28
Site 0.482 However, as shown in Table 2, compatible lymph
 Upper extremity 9 (33) 18 (67)
 Lower extremity 5 (45) 6 (55) axiality is hardly achieved in skin flap transfer
Operation 0.001† cases other than toe flap transfer cases when indo-
 Replantation 1 (6) 15 (94) cyanine green lymphography is not used for assis-
 Free flap 13 (59) 9 (41)
RLA║ 0.057 tance. Indocyanine green lymphography guidance
 Positive 2 (100) 0 (0) is essential to achieve compatible lymph axiality,
 Negative 12 (33) 24 (167) but is not possible in all cases. Because the primary
CLA¶ <0.001†
 Positive 1 (4) 24 (96) objective of skin flap transfer is coverage of a defect,
 Negative 13 (100) 0 (0) compatible lymph axiality can be achieved only
LFR, lymph flow restoration; RLA, raw surface in lymph axiality; when inset of a flap does not affect defect coverage.
CLA, compatible lymph axiality; ICG, indocyanine green. This study revealed other factors associated with
*Postoperative LFR between an amputee and a recipient site on ICG
lymphography. postoperative lymph flow restoration. Male sex,
†Statistically significant. defect caused by trauma, and replantation cases were
‡Skin defect caused by acute trauma.
§Skin defect caused by contracture release, tumor resection, or ulcer.
associated with a higher lymph flow restoration rate.
║Existence of raw surface area in main lymph flows. In this study cohort, more male and trauma cases
¶Compatible lymph axiality between amputee/flap and recipient site. were included in the replantation group. This can
be explained by the fact that replantation cases were
Table 4. Association between Lymph Axiality and
associated with a higher rate of positive compat-
Postoperative Lymph Circulation ible lymph axiality and lymph flow restoration, but
further studies are required to clarify independent
LFR- LFR- factors associated with lymph flow restoration with
Negative Positive
(%)* (%)* p a larger sample size, allowing multivariate analysis.
No. 14 24
Prolonged edema sometimes affects postop-
RLA-negative†/ erative rehabilitation, and can even develop as
CLA-positive‡ 0 (0) 24 (100) <0.001§ clinically significant lymphedema after replan-
Others║ 14 (100) 0 (0) tation surgery or free flap transfer, as shown in
LFR, lymph flow restoration; RLA, raw-surface in lymph axiality;
CLA, compatible lymph axiality; ICG, indocyanine green.
Figure 2.5,8,11,12 Once manifested, lymphedema
*Postoperative LFR between an amputee and a recipient site on ICG progresses over time and significantly deteriorates
lymphography. a patient’s quality of life.4,5,8,10,29–32 Based on the
†Existence of raw surface area in main lymph flows.
‡Compatible lymph axiality between amputee/flap and recipient site.
results of this study, a reconstructive surgeon can
§Statistically significant. restore lymph flows without a lymph node flap or
║Others include RLA-negative/CLA-negative, RLA-positive/CLA- supermicrosurgical lymphatic anastomosis; lymph
negative, and RLA-positive/CLA- positive.
flows can be restored when tissue is replanted/
transferred with compatible lymph axiality with-
axiality plays a critical role in lymph flow restora- out raw surface in lymph axiality. Lymph axiality-
tion after tissue replantation or transfer. based tissue transfer has a potential to allow more
If a raw region remains around the lymphat- physiologic reconstruction, facilitates postop-
ics in an amputee or a flap, formation of scar tis- erative rehabilitation, and prevents lymphedema
sue around the lymphatics inhibits lymph flow even when main lymph pathways are damaged.
restoration.7,9,10 If the direction of the lymph flow One of the limitations of the study is that only
is not in line with the existing flow proximal and/ a relatively small number of Japanese patients were
or distal to the defect, lymph flow restoration is included without long-term follow-up. It is unclear

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 Volume 142, Number 3 • Lymph Flow Restoration

Fig. 2. Case 3 in Table 1. A 28-year-old man suffering from crush amputation of the right middle finger under-
went replantation. Postoperative indocyanine green lymphography showed the linear pattern through the
replanted site; lymph flowed continuously beyond the replanted site (dotted line). Arrows indicate indocyanine
green injection site.

Fig. 3. Case 4 in Table 1. A 38-year-old man suffering from clean amputation of the penis underwent replanta-
tion. Postoperative indocyanine green lymphography showed a linear pattern through the replanted site; lymph
flowed continuously beyond the replanted site (dotted line). Arrows indicate indocyanine green injection site.

801
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 Plastic and Reconstructive Surgery • September 2018

Fig. 4. Case 5 in Table 1. A 42-year-old woman suffering from crush amputation of the left little finger under-
went replantation. Artificial dermis was used to cover a raw surface. Postoperative indocyanine green lym-
phography showed the stardust pattern in the replanted finger; lymph did not flow beyond the replanted site
(dotted line). Arrows indicate indocyanine green injection site.

Fig. 5. Case 9 in Table 2. A 70-year-old woman suffering from sarcoma in the right upper extremity underwent
wide resection and superficial circumflex iliac artery perforator flap transfer without indocyanine green lym-
phographic guidance. Postoperative indocyanine green lymphography showed the stardust pattern in the flap
and the recipient site, but the linear pattern was not seen in the flap; a diagnosis of secondary lymphedema
was made. Arrows indicate indocyanine green injection site; dotted circle indicates the flap margin; and dotted
arrows indicate expected lymph pathways in the flap.
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 142, Number 3 • Lymph Flow Restoration

Fig. 6. Case 18 in Table 2. A 54-year-old woman suffering from sarcoma in the right lower leg underwent wide
resection and transverse rectus abdominis myocutaneous flap transfer with indocyanine green lymphographic
guidance. The linear pattern was marked with a red pen based on preoperative indocyanine green lympho-
graphic findings. Postoperative indocyanine green lymphography showed the linear pattern in both the flap
and the recipient site, although the stardust pattern was seen in the distal edge of the flap; lymph flowed con-
tinuously beyond the edges of the flap. Arrows indicate indocyanine green injection site; dotted circle indicates
the flap margin; and dotted arrows indicate lymph pathways in the flap.

whether this study’s results can be applicable for
non-Japanese cases or whether the lymph axiality-
based tissue transfer method is clinically useful to
prevent lymphedema in long-term follow-up. Most
importantly, the lymph axiality-based tissue transfer
has yet to be clarified as being useful for the treat-
ment of established lymphedema. Theoretically,
lymph axiality-based tissue transfer seems to restore
arm lymph flows of patients with upper extremity
lymphedema after axillary lymph node dissection,
by transferring a skin flap at the axilla with com-
patible lymph axiality without lymph node inclu-
sion or supermicrosurgical lymphatic anastomosis.
Although supermicrosurgical lymphatic vessel anas-
tomosis allows secure restoration of lymph flows,
supermicrosurgical technique is required, which
can be performed only by experienced microsur-
geons; secure anastomosis technique for vessels with
diameter of 0.5 mm or smaller is required for super-
microsurgery.13,16,33 Because lymphedema treatment
with vascularized lymph node transfer has a risk of
donor-site lymphedema, lymph axiality-based tissue
transfer can be a useful therapeutic option for com-
pression-refractory lymphedema, with a minimum
risk of donor-site lymphedema.25,33–36 Further pro-
spective studies including a larger number of cases
with longer clinical follow-up are required to con-
firm the importance of lymph axiality in lymph flow
restoration, to confirm the usefulness of lymph axi-
ality-based tissue transfer in prevention and treat-
ment of lymphedema, and to evaluate which flap is
more useful for lymph axiality-based tissue transfer.
CONCLUSIONS
Lymph flows can be restored after tissue
replantation or free flap transfer without lymph
node or supermicrosurgical lymphatic anastomo-
sis. Lymph axiality–based tissue transfer, replant-
ing/transferring tissue with compatible lymph
axiality without raw surface in lymph axiality, is
considered a key for lymph flow restoration.
Takumi Yamamoto, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Center Hospital of National Center for Global Health and
Medicine
1-21-1 Toyama, Shinjuku-ku
Tokyo 162-8655, Japan
tyamamoto-tky@umin.ac.jp

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 Plastic and Reconstructive Surgery • September 2018
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