This is our latest and perhaps the most impactful article on the concept of performing lymphaticovenous anastomosis (LVA). In chronic lymphedema, lymphatic hypertension may cause lymphatic lumen dilatation and valvular dysfunction, making retrograde flow possible. For those who seek optimal LVA outcomes, it was believed that the use of side-to-end, side-to-side, and end-to-side (retrograde flow) lymphaticovenous anastomoses, based on the concept of retrograde flow, can help to reduce lymphedema. However, based on this study, retrograde anastomosis is not recommended because of no added benefit. This article will change the way LVA is performed. Only end-to-end and end-to-side (antegrade) anastomoses are recommended. Published in International Journal of Surgery (IF 13.4, ranked 5/211 among surgical journals, top 2.4%).