Lower Extremity Lymphedema with Leg Dermal Backflow Stage 2-3 Treated By the Superior-Edge-of-the-Knee Incision Method: Is a Single Lymphaticovenular Anastomosis Enough?

Background: Treating lymphedema is always challenging for microsurgeons. Application of the Superior-Edge-of-the-Knee Incision method for lymphaticovenular anastomosis is reported to have a strong therapeutic effect in patients treated for lower extremity lymphedema because lymph-to-venous flow at the anastomosis is enhanced by knee joint movement during normal walking.¹ We investigated whether a single lymphaticovenular anastomosis is adequate for early lower extremity lymphedema.

Methods:The study involved nine patients with lower extremity lymphedema characterized by stage 2–3 dermal backflow and treated by a single lymphaticovenular anastomosis at the thigh via the Superior-Edge-of-the-Knee Incision method. The lymphatic vessel and direction of flow were assessed intraoperatively, and reduction in lymphedema volume was assessed postoperatively.

Results: Use of our incision method yielded five anastomoses in the five patients with stage 2 dermal backflow and four anastomoses in the four patients with stage 3 dermal backflow. Mean diameter of the lymphatic vessel was 0.66 ± 0.09 mm (0.65±0.09 and 0.66±0.10 mm in the stage 2 and stage 3 patients, respectively; p=0.853). No venous reflux occurred in any patient. Mean follow up was 8.56 ± 3.28 months (7.80±1.64 months and 9.50±4.80 months for the stage 2 and 3 patients, respectively; p=0.535). The circumference of the affected limb was reduced in all patients. Mean reduction in the lower extremity lymphedema index was 22.999±9.701 (25.729±11.281 and 19.585±7.300 in the stage 2 and 3 patients, respectively; p=0.357).

Conclusions:A single lymphaticovenular anastomosis created by the Superior-Edge-of-the-Knee Incision method has a strong therapeutic effect in patients with stage 2–3 dermal backflow. Our treatment strategy using only a single lymphaticovenular anastomosis has the following advantages: only one microsurgeon with an operating microscope is needed; operation time is shortened by a single site lymphaticovenular anastomosis; large lymphatic vessels of adequate size for anastomosis can be detected; imaging is not needed for detection of lymphatic vessels.