Indocyanine Green Velocity: Lymph Transportation Capacity Deterioration With Progression of Lymphedema

Indocyanine green fluorescence applied to gynecologic oncology: beyond sentinel lymph node

Indocyanine green (ICG), a well-known molecule employed in medicine for over five decades, has emerged as a versatile dye widely embraced across various surgical disciplines. In gynecologic oncology, its prevalent use revolves around the detection of sentinel lymph nodes. However, the true potential of ICG extends beyond this singular application, owing to its pragmatic utility, cost-effectiveness, and safety profile. Furthermore, ICG has been introduced in the theranostic landscape, marking a significant juncture in the evolution of its clinical utility. This narrative review aims to describe the expanding horizons of ICG fluorescence in gynecologic oncology, beyond the sentinel lymph node biopsy. The manifold applications reported within this manuscript include: 1) lymphography; 2) angiography; 3) nerve visualization; 4) ICG-driven resections; and 5) theranostic. The extensive exploration across these numerous applications, some of which are still in the preclinical phase, serves as a hypothesis generator, aiming to stimulate the development of clinical studies capable of expanding the use of this drug in our field, enhancing the care of gynecological cancer patients.

Characteristic Single Photon Emission Computed Tomography-Computed Tomography Findings in Lower Extremity Lymphedema: Comparison to Indocyanine Green Lymphography

Introduction: Evaluation of lymph circulation is significant in lower extremity lymphedema (LEL) management. Single-photon emission computed tomography-computed tomography (SPECT-CT) has been introduced for lymphedema evaluation, but its characteristic findings are yet fully clarified. The purpose of this study was to reveal typical SPECT-CT findings in secondary LEL by contrasting with indocyanine green (ICG) lymphography findings. Methods: This is a single-center retrospective case-control study. Medical charts of cancer survivors who underwent SPECT-CT and ICG lymphography for secondary LEL were reviewed. Lymphedematous limbs were defined as ICG lymphography stage I-V and non-lymphedematous limbs were defined as ICG lymphography stage 0. Characteristic SPECT-CT findings were identified in early phase and delay phase, and prevalence of the findings was compared between lymphedematous limbs and non-lymphedematous limbs. Results: Thirty-four limbs of 17 patients were included in this study; 6 (17.6%) non-lymphedematous limbs and 28 (82.4%) lymphedematous limbs. Four characteristic SPECT-CT findings were identified; delayed enhancement of the main lower leg lymphatic pathway (DML), few delayed inguinal lymph nodes enhancement (FDN), early phase discontinuous enhancement of the main lymphatic pathway (EDM), and nonenhancement of the deep lymphatic pathways in early phase (NDE). Between lymphedematous and non-lymphedematous limbs, there were statistically significant differences in FDN (64.3% vs. 0%, p = 0.004) and EDM (67.9% vs. 0%, p = 0.002). Conclusions: FDN and EDM are characteristic SPECT-CT findings in secondary LEL.

Qualitative use of ICG angiography and lymphography in periorbital surgery

PURPOSE

Open imaging fluorescence devices have been utilized in surgical oncology, vascular and plastic surgery; however, the role of indocyanine green (ICG) in periorbital surgery and lymphatics has not been explored.

METHODS

A prospective, single-center diagnostic study was conducted from 2021 to 2022 utilizing ICG to assess both the periorbital vasculature and lymphatics. Fluorescence was captured with open-imaging fluorescent devices. For ICG angiography, a total of 5-10 mg of ICG was given intravenously at various time points to visualize intraoperative blood flow to eyelid flaps, vascular tumors, or extraocular muscles. For ICG lymphography, 0.03-0.06 mg of ICG was injected subcutaneously to visualize the periorbital and facial lymphatic drainage.

RESULTS

Twenty-two patients underwent ICG angiography. Periorbital vascular supply was seen in eyelid reconstructions (n = 8), anophthalmic reconstructions (n = 2), lacrimal gland tumors (n = 2), orbital venous malformations (n = 2), tumor metastasis (n = 1) and benign tumors (n = 1). The anterior ciliary arteries were visualized to the extraocular muscles in fracture repairs (n = 3) and muscle biopsies (n = 2). Ten patients underwent ICG lymphangiography highlighting the global periorbital lymphatic system.

CONCLUSION

ICG allows for visualization of the vasculature of extraocular muscles and tumors, assessing perfusion of flaps during reconstruction and the global periorbital lymphatic drainage pathways.

Treatment of Rat Lymphedema by Propeller Lymphatic Tissue Flap Combined with Nanofibrillar Collagen Scaffolds

BACKGROUND

 The aim of our study was to evaluate a new propeller vascularized lymphatic tissue flap (pVLNT) combined with aligned nanofibrillar collagen scaffolds (CS) (BioBridge) in reducing lymphedema in the rat lymphedema model.

METHODS

 Unilateral left hindlimb lymphedema was created in 15 female Sprague-Dawley rats following inguinal and popliteal lymph nodes (LN) resection and radiation. An inguinal pVLNT was elevated from the contralateral groin and transferred through a skin tunnel to the affected groin. Four collagen threads were attached to the flap and inserted in the hindlimb at the subcutaneous level in a fan shape. The three study groups consisted of group A (control), group B (pVLNT), and group C (pVLNT + CS). Volumetric analysis of both hindlimbs was performed using micro-computed tomography imaging before the surgery (at initial time point) and then at 1 and 4 months, postoperatively, and the relative volume difference (excess volume) was measured for each animal. Lymphatic drainage was assessed by indocyanine green (ICG) fluoroscopy for number and morphology of new collectors and the time required for ICG to move from injection point to the midline.

RESULTS

 Four months after the induction of lymphedema, an increased relative volume difference remained in group A (5.32 ± 4.74%), while there was a significant relative volume reduction in group B (-13.39 ± 8.55%) and an even greater reduction in group C (-14.56 ± 5.04%). ICG fluoroscopy proved the functional restoration of lymphatic vessels and viability of pVLNT in both B and C groups. Notably, only group C demonstrated statistically significant improvements in lymphatic pattern/morphology and in the number of lymphatic collectors as compared with the control group A.

CONCLUSION

 The pedicle lymphatic tissue flap combined with SC is an effective procedure for the treatment of lymphedema in rats. It can be easily translated into treatment of humans' lower and upper limb lymphedema and further clinical studies are warranted.

Lymph Node Transfer and Neolymphangiogenesis: From Theory to Evidence

BACKGROUND

Vascularized lymph node transfer (VLNT) has proven to be a valuable treatment for patients with advanced stages of lymphedema. Although spontaneous neolymphangiogenesis has been advocated to explain the positive effects of VLNT, there is still a lack of supportive biological evidence. The aim of this study was to demonstrate the postoperative formation of new lymphatic vessels using histologic skin sections from the lymphedematous limb.

METHODS

Patients with lymphedema of the extremities who had undergone gastroepiploic vascularized lymph node flap surgery between January of 2016 and December of 2018 were identified. Full-thickness 6-mm skin-punch biopsy specimens were obtained from patients at identical sites of the lymphedematous limb during the VLNT surgical procedure (T0) and 1 year later (T1). The histologic samples were immunostained with anti-podoplanin/gp36 antibody.

RESULTS

A total of 14 patients with lymph node transfer were included. At the 12-month follow-up, the mean circumference reduction rate was 44.3 ± 4.4 at the above-elbow/above-knee level and 60.9 ± 7 at the below-elbow/below-knee level. Podoplanin expression values were, on average, 7.92 ± 1.77 vessels/mm 2 at T0 and 11.79 ± 3.38 vessels/mm 2 at T1. The difference between preoperative and postoperative values was statistically significant ( P = 0.0008).

CONCLUSION

This study provides anatomic evidence that a neolymphangiogenic process is induced by the VLNT procedure because new functional lymphatic vessels can be detected in close proximity to the transferred lymph nodes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

In Vivo Dynamic and Static Analysis of Lymphatic Dysfunction in Lymphedema Using Near-Infrared Fluorescence Indocyanine Green Lymphangiography

BACKGROUND

Near-infrared fluorescence indocyanine green lymphangiography, a primary modality for detecting lymphedema, which is a disease due to lymphatic obstruction, enables real-time observations of lymphatics and reveals not only the spatial distribution of drainage (static analysis) but also information on the lymphatic contraction (dynamic analysis).

METHODS

We have produced total lymphatic obstruction in the upper limbs of 18 Sprague-Dawley rats through the dissection of proximal (brachial and axillary) lymph nodes and 20-Gy radiation (dissection limbs). After the model formation for 1 week, 9 animal models were observed for 6 weeks using near-infrared fluorescence indocyanine green lymphangiography by injecting 6-μL ICG-BSA (indocyanine green-bovine serum albumin) solution of 20-μg/mL concentration. The drainage pattern and leakage of lymph fluid were evaluated and time-domain signals of lymphatic contraction were observed in the distal lymphatic vessels. The obtained signals were converted to frequency-domain spectrums using signal processing.

RESULTS

The results of both static and dynamic analyses proved to be effective in accurately identifying the extent of lymphatic disruption in the dissection limbs. The static analysis showed abnormal drainage patterns and increased leakage of lymph fluid to the periphery of the vessels compared with the control (normal) limbs. Meanwhile, the waveforms were changed and the contractile signal frequency increased by 58% in the dynamic analysis. Specifically, our findings revealed that regular lymphatic contractions, observed at a frequency range of 0.08 to 0.13 Hz in the control limbs, were absent in the dissection limbs. The contractile regularity was not fully restored for the follow-up period, indicating a persistent lymphatic obstruction.

CONCLUSIONS

The dynamic analysis could detect the abnormalities of lymphatic circulation by observing the characteristics of signals, and it provided additional evaluation indicators that cannot be provided by the static analysis. Our findings may be useful for the early detection of the circulation problem as a functional evaluation indicator of the lymphatic system.

Lymphatic flow velocity is a predictor of functional lymphatic vessels for lymphaticovenous anastomosis

BACKGROUND

Indocyanine green (ICG) lymphography is widely used to localize functional lymphatic vessels for lymphaticovenous anastomosis (LVA); however, flow velocity is rarely assessed. We aimed to evaluate the correlation between lymphatic flow velocity and the presence of functional lymphatic vessels.

METHODS

Data of a total of 924 lymphatic vessels from 273 lymphedema patients who underwent LVA between July 2018 and December 2020 were retrospectively reviewed. Lymph flow velocity was defined by considering the most proximal anatomic location enhanced by ICG at 30 min after injection and categorized into four groups; grade 1 (foot or hand), grade 2 (below knee or elbow), grade 3 (at/above knee or eblow), or grade 4 (axilla or groin). The presence of functional lymphatic vessels, which showed lymphatic fluid flow when the vessels were cut for anastomosis, was compared between the four groups.

RESULTS

A higher rate of functional lymphatic vessels was observed among lymphatic vessels with grade 3 or 4 flow velocity compared with those with grade 1 or 2 flow velocity (67.5% vs. 44.5%; p < 0.001). These findings were consistent with the observations for lymphatic vessels with a non-linear pattern in ICG lymphography (59.4% vs. 26.5%; p < 0.001). The rate of completion of LVA at surgical sites in extremities with grade 3 or 4 flow velocity was 88.1% compared with 65.8% in extremities with grade 1 or 2 velocity (p < 0.001).

CONCLUSIONS

Lymph flow velocity grading can be a simple and easy adjunctive method to determine indication for LVA in extremities with lymphedema.

Office-Based Lymphatic Supermicrosurgery: Supermicrosurgical Lymphaticovenular Anastomosis at an Outpatient Clinic

BACKGROUND

 Supermicrosurgical lymphaticovenular anastomosis (LVA) has become popular for the treatment of compression-refractory lymphedema. With advancement of navigation tools, LVA can be performed with more ease and safety, allowing office-based LVA at an outpatient clinic.

METHODS

 Office-based LVA was performed on patients with compression-refractory secondary extremity lymphedema by a well-experienced supermicrosurgeon (T.Y.) under local infiltration anesthesia. Indocyanine green (ICG) lymphography and vein visualizer were used to localize vessels preoperatively. A stereoscopic microscope (Leica S6E, Leica Microsystems, Germany) or a relatively small operative microscope (OPMI pico, Carl Zeiss, Germany) was used for LVA. Operative records and postoperative results were reviewed to evaluate feasibility of office-based LVA.

RESULTS

 LVAs were performed on 27 arms and 42 legs, which resulted in 131 anastomoses via 117 incisions. ICG lymphography stage included stage II in 47 limbs, and stage III in 22 limbs. Time required for one LVA procedure (from skin incision to skin closure in one surgical field) ranged from 13 to 37 minutes (average, 24.9 minutes). One year after LVA, all cases showed significant volume reduction (lymphedematous volume reduction; 0.5-23.6%, average 13.23%). No postoperative complication was observed.

CONCLUSION

 LVA can be performed with safety and effectiveness outside an operation theater. Patient selection, precise preoperative mapping, and experience of a surgeon are key to successful office-based LVA.

Imaging of the Lymphatic Vessels for Surgical Planning: A Systematic Review

BACKGROUND

Secondary lymphedema is a common complication after surgical or radiotherapeutic cancer treatment. (Micro) surgical intervention such as lymphovenous bypass and vascularized lymph node transfer is a possible solution in patients who are refractory to conventional treatment. Adequate imaging is needed to identify functional lymphatic vessels and nearby veins for surgical planning.

METHODS

A systematic literature search of the Embase, MEDLINE ALL via Ovid, Web of Science Core Collection and Cochrane CENTRAL Register of Trials databases was conducted in February 2022. Studies reporting on lymphatic vessel detection in healthy subjects or secondary lymphedema of the limbs or head and neck were analyzed.

RESULTS

Overall, 129 lymphatic vessel imaging studies were included, and six imaging modalities were identified. The aim of the studies was diagnosis, severity staging, and/or surgical planning.

CONCLUSION

Due to its utility in surgical planning, near-infrared fluorescence lymphangiography (NIRF-L) has gained prominence in recent years relative to lymphoscintigraphy, the current gold standard for diagnosis and severity staging. Magnetic resonance lymphography (MRL) gives three-dimensional detailed information on the location of both lymphatic vessels and veins and the extent of fat hypertrophy; however, MRL is less practical for routine presurgical implementation due to its limited availability and high cost. High frequency ultrasound imaging can provide high resolution imaging of lymphatic vessels but is highly operator-dependent and accurate identification of lymphatic vessels is difficult. Finally, photoacoustic imaging (PAI) is a novel technique for visualization of functional lymphatic vessels and veins. More evidence is needed to evaluate the utility of PAI in surgical planning.

Spontaneous Lymph Flow Restoration in Free Flaps: A Pilot Study

BACKGROUND

Oncologic excision and trauma can be responsible for major defects and lymphedema. Free flaps are commonly used for reconstruction. We aimed to determine if lymphatic flow between flap and recipient site can be restored without lymphatic surgery.

METHODS

15 free flaps were performed in different patients in our center. Infrared-based lymphography was used to plan surgery. Indocyanine green (ICG) was injected in the flap's subdermal tissue and also at the edges of the skin defect. Circumferential lymphatic channels were marked 5 min after the ICG injection. Fluorescent images were recorded with an infrared camera system. The flap inset was obtained by putting side to side the flap markings and the recipient site markings. Infrared-based lymphography was performed on every patient one year after surgery. Spontaneous lymph flow restoration was judged positive if lymphatic connections were observed between the flap and the recipient site.

RESULTS

seven free ALT and eight DIEP flaps were performed. All ALT flaps were designed following the limb axis which is the lymphatic axiality. Spontaneous lymph flow restoration was observed for the seven ALT flaps. Eight DIEP flaps were designed upside down and one was designed following the lymph axiality. Spontaneous lymph flow restoration was only observed for the one designed following the lymph axiality.

CONCLUSIONS

designing reconstructive free flap regarding lymph axiality seems to improve spontaneous lymph flow restoration between flap and recipient site without any specific lymphatic surgery.

Association of lymphatic flow velocity with surgical outcomes in patients undergoing lymphovenous anastomosis for breast cancer-related lymphedema

PURPOSE

Lymphovenous anastomosis (LVA) is primarily used for treating early-stage lymphedema. Here, we aimed to investigate the relationship between lymphatic flow velocity and the efficacy of LVA in breast cancer-related lymphedema patients. To this end, we assessed the transit velocity of lymphatic fluid using indocyanine green (ICG) lymphography and radioisotope lymphoscintigraphy.

METHODS

We retrospectively examined patients diagnosed with breast cancer-related lymphedema who underwent LVA from January to December 2020. Patient data, including demographics, clinical stage, and postoperative surgical outcomes, were collected from electronic medical records. ICG lymphography results and dynamic lymphoscintigrams were analyzed to measure the lymphatic flow velocity and to determine the grade of the limb lymphedemas.

RESULTS

Eighty patients (all female, mean age of 53.6 years) were included. The lymphatic flow velocity ranged between 0.58 and 21.5 cm/min (average, 7.61 cm/min); 37 (46.3%), 18 (22.5%), 15 (18.8%), and 10 (12.5%) arm lymphedemas were classified as lymphoscintigraphy grade 0, 1, 2, and 3, respectively. A significant association was observed between lymphatic flow velocity and lymphedema grade determined using lymphoscintigraphy and between the amount of volume reduction after LVA and preoperative lymphatic flow velocity (P < 0.05).

CONCLUSIONS

Our findings suggest that lymphatic flow velocity is positively correlated with surgical outcomes in patients undergoing LVA. Therefore, surgical treatment plans for lymphedema should not be based only on the International Society of Lymphedema stage, because advanced-stage lymphedema patients with high ICG velocities can benefit from LVA alone.

Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach

Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.

ICG lymphographic findings following immediate lymphatic reconstruction in breast cancer patients

BACKGROUND

Immediate lymphatic reconstruction (ILR), performed at the time of axillary lymph node dissection (ALND), has demonstrated promising reductions in breast cancer-associated lymphedema. However, questions remain over the effects of adjuvant therapies on the continued patency of the lymphaticovenous anastomosis. Our study aimed to assess lymphographic outcomes, including ICG pattern and LVB patency, in patients at high risk for breast cancer-associated lymphedema following axillary ILR.

METHODS

Baseline ICG lymphography studies performed during ILR of 15 patients were compared to repeat ICG studies obtained during second-stage breast reconstructive procedures to assess for changes in lymphatic flow patterns through the at-risk arm and transit into the axilla.

RESULTS

All 15 patients in this study demonstrated linear lymphatic flow in baseline lymphography. Repeat lymphographic studies showed linear lymphatic transit in 12/15 patients. Of these 12 patients, 10 received chemotherapy, and all 12 received post-mastectomy radiation (PMRT). Dermal backflow patterns were recorded in 3/15 patients. All 3 patients received chemotherapy and 2/3 underwent PMRT. Additionally, repeat ICG studies of 7/12 lymphedema-free patients demonstrated clear visualization of linear ICG flow from the lymphatics of the arm into the axilla.

CONCLUSION

We have demonstrated that ICG lymphography can be implemented as a postoperative tool to assess lymphatic function in patients who have undergone ILR in the axilla. Repeat ICG studies in the majority of patients demonstrated linear ICG flow similar to baseline studies. Additionally, ICG flow patterns through the axilla in repeat lymphography provided visual evidence supporting sustained LVB patency, despite axillary irradiation.

Indocyanine Green Lymphography for Evaluation of Breast Lymphedema Secondary to Breast Cancer Treatments

BACKGROUND

 Although breast lymphedema (BL) significantly deteriorates quality of life (QOL) of breast cancer survivors, little is known and pathophysiological severity staging system is yet reported. This study aimed to evaluate usefulness of a novel BL severity staging system based on indocyanine green (ICG) lymphography findings.

METHODS

 Breast cancer survivors with breast symptoms who underwent breast ICG lymphography were included. Breast ICG lymphography stage was determined based on visibility of linear pattern and extension of dermal backflow patterns. Prevalence of breast symptoms and lymphedema QOL score (LeQOLiS) was compared according to the stage.

RESULTS

 Thirty-seven patients were included. Breast ICG lymphography stage included stage 0 in 11 (29.7%) cases, stage I in 3 (8.1%) cases, stage II in 11 (29.7%) cases, stage III in 6 (16.2%) cases, stage IV in 4 (10.8%) cases, and stage V in 2 (5.4%) cases. Higher ICG stages were associated with more frequent prevalence of breast swelling (p = 0.020), breast pain (p = 0.238), and breast cellulitis (p = 0.024), and with higher LeQOLiS (p < 0.001).

CONCLUSION

 ICG lymphography allows clear visualization of superficial lymph circulation in the breast. Higher breast ICG lymphography stages are associated with more frequent prevalence of BL-related symptoms and worse QOL.

Indocyanine green lymphography as novel tool to assess lymphatics in patients with lipedema

OBJECTIVE

Lipedema is a chronic and progressive disease associated with lymphatic impairment at later stages. The aim of our study was to describe the functional status and anatomy of lower limb superficial lymphatic system using indocyanine green (ICG) lymphography in patients with lipedema.

METHODS

Following ICG injection at the dorsum of the foot, distance (cm) covered by the dye at 10 (T10') and 25 min (T25') was measured and normalized for limb length. If the dye did not reach the groin within 25 min, patients were classified as "drainage-needing" group (DNG). Values of fat and lean distribution assessed by dual-energy X-ray absorptiometry were extracted, and correlation analysis was performed. Furthermore, anatomical patterns of superficial lymphatics were assessed.

RESULTS

Overall, 45 women were included, 25 (56%) of whom were classified as DNG. Symptoms duration was significantly associated with DNG status at multivariate analysis (odds ratio 1.07; 95% CI 1.01-1.14; p = 0.047). Moreover, Spearman's analysis showed a negative correlation between symptoms duration and T25' dye migration (r = -0.469; p = 0.037). Overall, no major anatomical lymphatic changes were found.

CONCLUSIONS

Present study suggests that lymphatic functioning in patients with lipedema correlates with symptoms duration. Further research on larger cohorts should verify our findings and clarify their potential therapeutic implications. Overall, ICG lymphography may be promising technique to assess both lymphatic anatomy and functioning in patients with lipedema.

Lymphaticovenous Anastomosis for Age-Related Lymphedema

INTRODUCTION

Primary lymphedema is usually caused by intrinsic disruption or genetic damage to the lymphatics but may also be the result of age-related deterioration of the lymphatics. The aims of this study were to determine the characteristics of age-related lymphedema and to assess the effectiveness of lymphaticovenous anastomosis (LVA) in its treatment.

METHODS

Eighty-six patients with primary lymphedema affecting 150 lower limbs were divided into three groups according to whether the age of onset was younger than 35 years, 35-64 years, or 65 years or older. Indocyanine green (ICG) lymphography was performed, followed by LVA surgery. ICG lymphography images were visually classified according to whether the pattern was linear, low enhancement (LE), distal dermal backflow (dDB), or extended dermal backflow (eDB). The lower extremity lymphedema (LEL) index score was calculated before and after LVA. Lymphatic vessel diameter and detection rates were also recorded.

RESULTS

In the ≥65 group, the lymphedema was bilateral in 54 patients and unilateral in 1 patient. There was statistically significant deterioration in the LEL index score with progression from the linear, LE, dDB through to the eDB pattern in the ≥65 group. The lymphatic vessel diameter was significantly greater in the ≥65 group. The rate of improvement was highest in the ≥65 group.

CONCLUSION

Age-related lymphedema was bilateral and deterioration started distally. The lymphatic vessels in patients with age-related lymphedema tended to be ectatic, which is advantageous for LVA and may increase the improvement rate.

Development and Clinical Validation of the LymphMonitor Technology to Quantitatively Assess Lymphatic Function

Current diagnostic methods for evaluating the functionality of the lymphatic vascular system usually do not provide quantitative data and suffer from many limitations including high costs, complexity, and the need to perform them in hospital settings. In this work, we present a quantitative, simple outpatient technology named LymphMonitor to quantitatively assess lymphatic function. This method is based on the painless injection of the lymphatic-specific near-infrared fluorescent tracer indocyanine green complexed with human serum albumin, using MicronJet600^TM microneedles, and monitoring the disappearance of the fluorescence signal at the injection site over time using a portable detection device named LymphMeter. This technology was investigated in 10 patients with unilateral leg or arm lymphedema. After injection of a tracer solution into each limb, the signal was measured over 3 h and the area under the normalized clearance curve was calculated to quantify the lymphatic function. A statistically significant difference in lymphatic clearance in the healthy versus the lymphedema extremities was found, based on the obtained area under curves of the normalized clearance curves. This study provides the first evidence that the LymphMonitor technology has the potential to diagnose and monitor the lymphatic function in patients.

A phase III, multicenter, single-arm study to assess the utility of indocyanine green fluorescent lymphography in the treatment of secondary lymphedema

OBJECTIVE

Indocyanine green (ICG) fluorescent lymphography might be useful for assessing patients undergoing lymphatic surgery for secondary lymphedema. The present clinical trial aimed to confirm whether ICG fluorescent lymphography would be useful in evaluating lymphedema, identifying lymphatic vessels suitable for anastomosis, and confirming patency of lymphaticovenular anastomosis in patients with secondary lymphedema.

METHODS

The present phase III, multicenter, single-arm, open-label, clinical trial (HAMAMATSU-ICG study) investigated the accuracy of lymphedema diagnosis via ICG fluorescent lymphography compared with lymphoscintigraphy, rate of identification of lymphatic vessels at the incision site, and efficacy for confirming patency of lymphaticovenular anastomosis. The external diameter of the identified lymphatic vessels and the distance from the skin surface to the lymphatic vessels using preoperative ICG fluorescent lymphography were measured intraoperatively under surgical microscopy.

RESULTS

When the clinical decision for surgery at each research site was made, the standard diagnosis of lymphedema was considered correct. For the 26 upper extremities, a central judgment committee who was unaware of the clinical presentation confirmed the imaging diagnosis was accurate for 100.0% of cases, whether the assessments had been performed via lymphoscintigraphy or ICG lymphography. In contrast, for the 88 lower extremities, the accuracy of the diagnosis compared with the diagnosis by the central judgment committee was 70.5% and 88.2% for lymphoscintigraphy and ICG lymphography, respectively. The external diameter of the identified lymphatic vessels was significantly greater in the lower extremities than in the upper extremities (0.54 ± 0.21 mm vs 0.42 ± 0.14 mm; P < .0001). Also, the distance from the skin surface to the lymphatic vessels was significantly longer in the lower extremities than in the upper extremities (5.8 ± 3.5 mm vs 4.4 ± 2.6 mm; P = .01). For 263 skin incisions, with the site placement determined using ICG fluorescent lymphography, the rate of identification of lymphatics vessels suitable for anastomosis was 97.7% (95% confidence interval, 95.1%-99.2%). A total of 267 lymphaticovenular anastomoses were performed. ICG fluorescent lymphography was judged as "useful" for confirming patency after the anastomosis in 95.1% of the cases.

CONCLUSIONS

ICG fluorescent lymphography could be useful for improving the treatment of patients with secondary lymphedema from the outpatient setting to surgery.

Radical reduction and reconstruction for male genital elephantiasis: Superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer after elephantiasis tissue resection

BACKGROUND

Treatment of elephantiasis, the most severe lymphedema, is challenging. Management of male genital elephantiasis (MGE) is even more challenging than extremity elephantiasis due to its complicated shape and high risk of lymphorrhea and cellulitis. Complete resection of fibrous tissue and lymphatic reconstruction is considered to be ideal for the treatment of MGE. The aim of this study was to evaluate the feasibility of radical reduction and reconstruction (3R) for isolated MGE.

METHODS

Medical charts of patients who underwent 3R were reviewed. The 3R operation consisted of genital fibrous tissue resection and reconstruction of soft tissue and lymphatic structure using superficial circumflex iliac artery perforator (SCIP) lymphatic flap transfer (LFT). No compression was applied postoperatively. Patient and flap characteristics, intraoperative findings, and postoperative results were evaluated.

RESULTS

Seven patients were included. MGE included isolated scrotal elephantiasis in 4 cases, and scrotal and penile elephantiasis in 3 cases. Resected tissue volume ranged from 609 to 2304 grams (average, 1511.0 grams). SCIP-LFT was performed in all cases; pedicled full-thickness SCIP-LFT for scrotal reconstruction in all cases, and SCIP pure-skin-perforator flap transfer for penile reconstruction in 3 cases. There was no postoperative genital complication or evidence of genital lymphedema recurrence in the mean follow-up period of 22.7 months. Genital lymphedema scores significantly improved postoperatively (6.7 ± 1.8 vs. 0.3 ± 0.5, P <0.001).

CONCLUSIONS

3R operation allowed one-stage curative treatment for MGE. LFT has the potential to play an essential role in the prevention of postoperative wound complications and lymphedema recurrence after radical resection of fibrotic tissue.

It was just mind blowing to be honest: a qualitative phenomenological study exploring cancer survivor's experiences of indocyanine green lymphography used to inform lymphedema therapy management

PURPOSE

A diagnosis of secondary lymphedema following cancer treatment can necessitate lifelong therapy. Indocyanine green (ICG) lymphography is a technique for visualising lymphatics to enable individualised lymphedema diagnosis, staging and therapy prescription. The participant experience of undergoing the procedure and the impact of imaging findings on lymphedema management is unknown. This study aimed to explore participant's experiences of ICG lymphography to inform cancer-related lymphedema therapy.

METHODS

A qualitative phenomenological study was conducted using semi-structured interviews with 17 adult participants who had undergone ICG lymphography for stage 0 to 2 upper or lower limb secondary cancer-related lymphedema (International Society of Lymphology, Lymphology 53(1):3-10, 2020).

RESULTS

Seventeen participants were included in the study ranging in age from 36 to 78 years (M = 53.8 years), the majority had a primary diagnosis of breast cancer (N = 7) or melanoma (N = 7). Three overarching themes emerged. Firstly, describing the experience of the ICG lymphography procedure. Secondly, the new knowledge explained symptoms and tailored treatment. Participants reflected on how seeing their lymphatic system helped in understanding about their lymphedema symptoms and guided changes towards more individualised lymphedema management. The final theme described the internal impact of self-knowledge, which included impacts of the new information on empowerment and motivation to self-manage participant's condition as well as their feelings.

CONCLUSIONS

ICG lymphography had beneficial impacts on participant's understanding of their lymphedema symptoms and often led to changes in management, positive outcomes in response to management changes and peace of mind about management plans, leading to feeling more empowered to self-manage their condition.

Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis

BACKGROUND

Lymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis.

METHODS

Medical charts of 122 free flap reconstruction cases, either with conventional flap transfer (control) or lymph-interpositional-flap transfer (LIFT), for extremity soft tissue defects including lymphatic pathways were reviewed. Lymph vessels' stumps in a flap were placed as close to those in a recipient site as possible under indocyanine green (ICG) lymphography navigation in LIFT group. LIFT group was subdivided into LIFT(+) and LIFT(-) groups; lymph vessels' stumps could be approximated within 2 cm in LIFT(+) group, whereas those could not be in LIFT(-) group. Lymph flow restoration (LFR) and lymphedema development (LED) rates were compared between the groups on postoperative 6 months.

RESULTS

No flap included lymph node. LFR was observed in 50 cases and LED in 72 cases. LFR rate in LIFT group (n = 75) was significantly higher than that in control group (n = 47) (57.3% vs. 14.9%; P < 0.001). LED rate in LIFT group was significantly lower than that in control group (20.0% vs. 48.9%; P < 0.001). Sub-group analysis showed significantly higher LFR and lower LED rates in LIFT(+) group (n = 44) than those in LIFT(-) group (n = 31; 88.6% vs. 12.9%; P < 0.001, 4.5% vs. 41.9%; P < 0.001).

CONCLUSIONS

LIFT allows simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis, which prevents development of secondary lymphedema.

The application of indocyanine green (ICG) and near-infrared (NIR) fluorescence imaging for assessment of the lymphatic system in reconstructive lymphaticovenular anastomosis surgery

INTRODUCTION

Lymphedema has traditionally been managed through noninvasive means with complete decongestive therapy. However, complete decongestive therapy is an intensive program that requires lifelong adherence by patients with lymphedema. More recently, reconstructive surgical procedures have shown promise in improving lymphedema by physiologically restoring lymphatic function. One of these types of procedures, lymphaticovenular anastomosis, relies on technological advances in imaging, particularly indocyanine green lymphangiography.

AREAS COVERED

This article reviews indocyanine green and near-infrared fluorescence imaging. In addition, this article discusses the application of this imaging to the preoperative, intraoperative, and postoperative assessment of the lymphatic system in the setting of lymphaticovenular anastomosis surgery.

EXPERT OPINION

Indocyanine green lymphangiography offers significant advantages over other types of imaging of the lymphatic system. In the future, it is hopeful that additional options for these imaging devices will become available which may increase their accessibility by centers interested in performing reconstructive lymphatic surgery, including in relation to cost. Finally, more studies with higher levels of evidence are needed to better define the long-term outcomes associated with lymphatic surgery including LVA. In this regard, practitioners should fully harness the information conferred by ICG lymphangiography as both a clinical and research tool.

Can Lymph Transportation Capacity Predict Treatment Efficacy of Lower Extremity Lymphedema by LVA?

Treatment outcomes for lower extremity lymphedema (LEL) using multiple lymphaticovenular anastomoses (LVA) are still uncertain. Classification of progression of lymphedema by disease staging is a potential preoperative predictor of the efficacy of treatment, but it is difficult to judge progression of lymphedema objectively. Recent studies have indicated that lymph pump dysfunction, which reflects lymph transportation capacity, is associated with lymphedema progression. Indocyanine green (ICG) lymphography, a minimally invasive modality for pathophysiological assessment of lymphedema, can be used for rapid and objective measurement of ICG velocity (ICGv) and transit time to the knee (TTk), which are parameters of lymph transportation capacity, over a certain period. In the current study, we analyzed the relationship between these parameters and outcomes for LEL treated by multiple LVA. Thirty-four consecutive patients who underwent multiple LVA and ICG lymphography were enrolled in the study. The relationship of ICGv and TTk with the efficacy of treatment by LVA (LEL index reduction) was investigated using Pearson correlation coefficient analysis. LEL index reduction was more strongly correlated with ICGv than with TTk, whereas it was weakly correlated with both quantification methods of lymph pump function (r > 0.6). Both ICGv and TTk are objective and simple parameters that can measure lymph pump functions quickly. Lymph pump function, especially calculated with ICGv, might help predict the treatment efficacy and objective evaluation after therapeutic intervention using multiple LVA.

Intraoperative Real-Time Visualization of the Lymphatic Vessels Using Microscope-Integrated Laser Tomography

BACKGROUND

 Detection and selection of the lymphatic vessels are important for maximizing therapeutic efficacy of lymphaticovenular anastomosis (LVA). Some imaging modalities have been reported to be useful for intraoperative identification of the lymphatic vessels, but they have limitations. In this article, we present new capabilities of intraoperative laser tomography, which was used to evaluate the lumen of the lymphatic vessel and to validate the patency of anastomosis.

METHODS

 Fifty-two patients with upper extremity lymphedema secondary to breast cancer treatment underwent indocyanine green (ICG) lymphography and real-time laser tomography imaging of ICG-enhanced lymphatic vessels intraoperatively before transecting the vessels during LVA. The imaging findings of the lymphatic vessels in laser tomography were investigated. Time required for scanning of the lymphatic vessels was compared between laser tomography and ultrasonography. The correlation between the thickness of the lymphatic vessel wall measured with laser tomographic imaging and the histologically measured thickness of the lymphatic vessel wall was examined. The patency of anastomosis sites was determined based on the image using laser tomography immediately after establishment of LVA.

RESULTS

 A total of 132 ICG-enhanced lymphatic vessels were scanned with laser tomography showing clear lumen with surrounding vessel wall. The required time for lymphatic vessel scanning was significantly shorter with laser tomography than with ultrasonography (1.6 ± 0.3 vs. 4.8 ± 1.2 minutes; p = 0.016). Strong correlation was seen between the thickness of the lymphatic vessels wall measured using laser tomography and the histologically measured thickness of the lymphatic vessel wall (r = 0.977, 95% confidence interval: 0.897-0.992, p < 0.001). The quality of patency was evaluated immediately after anastomosis, which assisted in deciding whether reanastomosis was needed.

CONCLUSION

 Microscope-integrated laser tomography provides real-time images of the lymphatic vessels in extremely high resolution and enables evaluation of lymphatic lumen condition and objective post-LVA anastomosis status.

Lymphedema secondary to melanoma treatments: diagnosis, evaluation, and treatments

Approximately 300,000 new cases of melanoma are annually diagnosed in the world. Advanced stage melanomas require sentinel lymph node biopsy (SLNB), sometimes lymph node dissections (LND). The development rate of lower extremity lymphedema ranges from 7.6% to 35.1% after inguinal SLNB, and from 48.8% to 82.5% after inguinal LND. Development rate of upper extremity lymphedema ranges from 4.4% to 14.6% after axillary LND. Lymphedema management has constantly improved but effective evaluation and surgical management such as supermicrosurgical lymphaticovenular anastomosis (LVA) are becoming common as minimally invasive lymphatic surgery. Diagnosis and new classification using indocyanine green lymphography allowing pre-clinical secondary lymphedema stage management are improving effectiveness of supermicrosurgical LVA and vascularized lymph node transfer. Lymphatic transfer with lymph-interpositional-flap can restore lymph flow after large oncologic excision even without performing lymphatic anastomosis. Since lymphatic reconstructive surgery may affect local to systemic dissemination of remnant tumor cells, careful consideration is required to evaluate indication of surgical treatments.

HAMAMATSU-ICG study: Protocol for a phase III, multicentre, single-arm study to assess the usefulness of indocyanine green fluorescent lymphography in assessing secondary lymphoedema

Introduction

Secondary lymphoedema of the extremities is an important quality-of-life issue for patients who were treated for their malignancies. Indocyanine green (ICG) fluorescent lymphography may be helpful for assessing lymphoedema and for planning lymphaticovenular anastomosis (LVA). The objective of the present clinical trial is to confirm whether or not ICG fluorescent lymphography using the near-infrared monitoring camera is useful for assessing the indication for LVA, for the identification of the lymphatic vessels before the conduct of LVA, and for the confirmation of the patency of the anastomosis site during surgery.

Methods and analysis

This trial is a phase III, multicentre, single-arm, open-label clinical trial to assess the efficacy and safety of ICG fluorescent lymphography when assessing and treating lymphoedema of patients with secondary lymphoedema who are under consideration for LVA. The primary endpoint is the identification rate of the lymphatic vessels at the incision site based on ICG fluorescent lymphograms obtained before surgery. The secondary endpoints are 1) the sensitivity and specificity of dermal back flow determined by ICG fluorescent lymphography as compared with ^99mTc lymphoscintigraphy—one of the standard diagnostic methods and 2) the usefulness of ICG fluorescent lymphography when confirming the patency of the anastomosis site after LVA.

Ethics and dissemination

The protocol for the study was approved by the Institutional Review Board of each institution. The trial was filed for and registered at the Pharmaceuticals and Medical Devices Agency in Japan. The trial is currently on-going and is scheduled to end in June 2020.

Trial registration number

jRCT2031190064; Pre-results.

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This study will examine the efficacy of a highly safe drug, indocyanine green for evaluating lymphatic anatomy.

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This is the first, multicentre, prospective, systematised clinical trial of Indocyanine green lymphography.

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The present clinical trial will not allow the assessment of the therapeutic efficacy of lymphaticovenular anastomosis.

Supermicrosurgery for oncologic reconstructions

With advancement of microsurgical techniques, supermicrosurgery has been developed. Supermicrosurgery allows manipulation (dissection and anastomosis) of vessels and nerves with an external diameter of 0.5 mm or smaller. Because quality of life of cancer survivors is becoming a major issue, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques attracts attention. Conventional free flap reconstruction usually sacrifices major vessels and muscle functions, whereas supermicrosurgical free flaps can be transferred from anywhere using innominate vessels without sacrifice of major vessel/muscle. Since a 0.1-0.5 mm vessel can be anastomosed, patient-oriented least invasive reconstruction can be accomplished with supermicrosurgery. Another important technique is lymphatic anastomosis. Only with supermicrosurgery, lymph vessels can be securely anastomosed, because lymph vessel diameter is usually smaller than 0.5 mm. With clinical application of lymphatic supermicrosurgery, various least invasive lymphatic reconstruction has become possible. Lymphatic reconstruction plays an important role in prevention and treatment of lymphatic diseases following oncologic surgery such as lymphedema, lymphorrhea, and lymphocyst. With supermicrosurgery, various tissues such as skin/fat, fascia, bone, tendon, ligament, muscle, and nerves can be used in combination to reconstruct complicated defects; including 3-dimensional inset with multi-component tissue transfer.

Technological Advances in Lymphatic Surgery: Bringing to Light the Invisible

Lymphatic surgery has become an integral and flourishing component of the field of plastic surgery. The diversity of ongoing technological innovations in perioperative imaging, including intraoperative dyes and cameras, allows plastic surgeons to work at the supermicrosurgical level. This study aims to highlight innovations that have shaped and will continue to revolutionize the perioperative management of the lymphatic surgery patient in the future. As additional advances emerge, we need a systematic and objective way to evaluate the efficacy and clinical integration readiness of such technologies. Undoubtedly, these technologies will help lymphatic surgery trend toward increasing objectivity, which will be critical for continued evolution and advancement.

Optimal Sites for Supermicrosurgical Lymphaticovenular Anastomosis: An Analysis of Lymphatic Vessel Detection Rates on 840 Surgical Fields in Lower Extremity Lymphedema Patients

BACKGROUND

Supermicrosurgical lymphaticovenular anastomosis is becoming a useful treatment option for progressive lower extremity lymphedema because of its minimal invasiveness. Finding a lymphatic vessel is a minimum requirement for lymphaticovenular anastomosis surgery, but no study has reported comprehensive analysis on factors associated with lymphatic vessel detection.

METHODS

One hundred thirty-four female secondary lower extremity lymphedema patients who underwent indocyanine green lymphography and lymphaticovenular anastomosis without a history of lymphedema surgery were included. Medical charts were reviewed to obtain clinical, indocyanine green lymphographic, and intraoperative findings. Lymphatic vessel detection was defined as positive when one or more lymphatic vessels were found in a surgical field of lymphaticovenular anastomosis. Logistic regression analysis was used to identify independent factors associated with lymphatic vessel detection.

RESULTS

Patient age ranged from 36 to 81 years, duration of edema ranged from 3 to 324 months, and body mass index ranged from 16.2 to 33.3 kg/m. Forty-eight patients (35.8 percent) had a history of radiation therapy, and 76 patients (56.7 percent) had a history of cellulitis. Lymphaticovenular anastomoses were performed in 840 surgical fields, among which lymphatic vessel detection was positive in 807 fields; the overall lymphatic vessel detection rate was 96.1 percent. Multivariate analysis revealed inverse associations in higher body mass index (OR, 0.323; p = 0.008) and the S-region/D-region on indocyanine green lymphography compared with the L-region (OR, 1.049 × 10(-8)/1.724 × 10(-9); p < 0.001/p < 0.001).

CONCLUSIONS

Independent factors associated with lymphatic vessel detection were clarified. Lower body mass index and L-region on indocyanine green lymphography are favorable conditions for finding lymphatic vessels in lower extremity lymphedema patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Onco-reconstructive supermicrosurgery

Supermicrosurgery is sophisticated microsurgical technique, which allows dissection and anastomosis of blood/lymphatic vessels and nerves with external diameter of 0.5 mm or smaller. With increasing attention to quality of life of cancer survivors, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques is warranted. Unlike conventional free flap reconstruction, supermicrosurgical free flaps can be elevated from anywhere using innominate vessels with diameter of 0.1 mm or larger, allowing patient-oriented least invasive reconstruction. Since lymphatic vessels can be anastomosed, lymphatic reconstruction is possible with supermicrosurgery, which plays an important role in management of cancer-related lymphedema. Supermicrosurgeons can harvest vascularized tissues such as skin, fat, fascia, tendon, ligament, bone, muscle, and nerve separately, and reconstruct complicated defects with three-dimensionally-inset multi-component tissue transfer.

Tackling the diversity of breast cancer related lymphedema: Perspectives on diagnosis, risk assessment, and clinical management

Breast cancer related lymphedema (BCRL) develops as a consequence of surgical treatment and/or radiation therapy in a significant number of breast cancer patients. The etiology of this condition is multifactorial and has not yet been completely elucidated. Risk factors include high body mass index, radical surgical procedures (i.e. mastectomy and axillary lymph node dissection), number of lymph nodes removed and number of metastatic lymph nodes, as well as nodal radiation, and chemotherapy. However, these predisposing factors explain only partially the BCRL occurrence, suggesting the possible involvement of individual determinants. Despite the implementation of conservative approaches, BCRL still remains in a proportion of cases an incurable and progressive condition with major physical and psychological implications. To date, diagnostic methods and staging systems lack uniformity, leading to a possible underestimation of the real incidence of this condition, decreasing early detection and thus the possibility of an effective treatment. Several preventive and therapeutic options are available, both conservative and surgical, but are not included in a standardized intervention protocol, tailored on patient's specific characteristics. In this review, we provide a comprehensive overview of the current state-of-knowledge of BCRL management, novel advantages in the assessment of pre-operative evaluation and risk prediction and discuss strengths and weaknesses of diagnostic and treatment strategies currently accessible in clinical practice.

Factors Associated with Lymphosclerosis: An Analysis on 962 Lymphatic Vessels

BACKGROUND

Lymphaticovenular anastomosis is a useful treatment option for compression-refractory lower extremity lymphedema, but its efficacy depends largely on the severity of lymphosclerosis. To maximize lymphaticovenular anastomosis efficacy, it is important to elucidate factors associated with severe lymphosclerosis.

METHODS

Medical charts of 134 lower extremity lymphedema patients who underwent preoperative indocyanine green lymphography and lymphaticovenular anastomosis were reviewed to obtain data of clinical demographics, indocyanine green lymphography findings, and intraoperative findings. Based on intraoperative findings of lymphatic vessels, severity of lymphosclerosis was classified into s0, s1, s2, and s3. Severe lymphosclerosis was defined as lymphatic vessels with s3 sclerosis. Logistic regression analysis was used to identify independent factors associated with severe lymphosclerosis.

RESULTS

In total, 962 lymphatic vessels were analyzed, among which severe lymphosclerosis was observed in 97 (10.1 percent). Multivariate analysis revealed that independent factors associated with severe lymphosclerosis were higher body mass index (OR, 1.803; 95 percent CI, 1.041 to 3.123; p = 0.035), incision site in the thigh/foot compared with in the groin (OR, 2.355/4.471; 95 percent CI, 1.201 to 4.617/2.135 to 9.362; p = 0.013/p < 0.001), and S-region/D-region on indocyanine green lymphography compared with L-region (OR, 83.134/1441.126; 95 percent CI, 11.296 to 611.843/146.782 to 14149.195; p < 0.001/p < 0.001). Inverse associations were observed in positive history of radiation therapy (OR, 0.461; 95 percent CI, 0.269 to 0.788; p = 0.005).

CONCLUSIONS

Independent factors associated with severe lymphosclerosis were clarified. Indocyanine green lymphography pattern had the strongest association with severe lymphosclerosis. D-region on indocyanine green lymphography should be avoided for lymphaticovenular anastomosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Lymphatic and Sensory Function of the Upper Limb After Brachioplasty in Post-Bariatric Massive Weight Loss Patients

BACKGROUND

Varied deformities of the upper arm are common after massive weight loss. Brachioplasty techniques have been successively modified to improve aesthetic outcomes and avoid complications, especially lymphedema and sensory damage.

OBJECTIVES

The authors evaluated lymphatic drainage and sensory function of the upper limbs after brachioplasty performed with a double-ellipse marking technique, a medial incision, superficial undermining, and posterior arm liposuction.

METHODS

This prospective study included 12 women who underwent brachioplasty after bariatric surgery and massive weight loss. Lymphatic drainage was evaluated by forearm volumetry and indocyanine green lymphography of the entire limb. Cutaneous sensitivity thresholds were determined with Semmes-Weinstein monofilaments.

RESULTS

Patients received postoperative follow up for 12 months. Complications included a small dehiscence for 1 patient and hypertrophic scarring for 2 patients. Cutaneous sensitivity and forearm volumetry were unchanged after brachioplasty for all patients. Results of indocyanine green lymphography indicated that all patients had normal linear lymphatic patterns pre- and postoperatively.

CONCLUSIONS

Results of the study support the belief that this type of brachioplasty does not disrupt sensory or lymphatic function of the limb.

LEVEL OF EVIDENCE

4.

Lymphatic mapping of the upper limb with lymphedema before lymphatic supermicrosurgery by mirroring of the healthy limb

INTRODUCTION

Supermicrosurgical lymphatic-venous anastomosis (LVA) can improve limbs lymphedema. We describe a technique that we employ for preoperative lymphatic mapping of the upper limb (UL), when indocyanine green (ICG) lymphography shows only dermal backflow (DB) and no lymphatic vessel is detectable.

PATIENTS AND METHODS

Sixteen patients undergoing LVA for unilateral UL lymphedema, showing "stardust" or "diffuse" DB pattern, were included. Demographic, clinical data, and limbs measurements were recorded. LymQoL arm questionnaire was administered. Mean age of patients was 58.8 ± 13.1 years. Fifteen were females and 1 male. Lymphatic anatomy of the healthy limb was investigated by ICG lymphography and reported on the affected limb by a four steps technique: marking the main lymphatic pathway on the healthy limb, measuring of the distances at seven levels between the pathway and a line joining fixed landmarks, reporting these measurements on the affected limb with a correction proportional to the degree of swelling, marking skin incisions at the intersection of this pathway with venules, individuated by near infrared light system. Results were analyzed by postoperative questionnaire and changes of limb measurements.

RESULTS

For every limb, we could find 3 ± 0.73 incision sites each containing at least one lymphatic vessel suitable for anastomosis. In every patient, we could perform 3.38 ± 0.62 anastomoses. Mean follow-up was 12.13 ± 2.73 months. After surgery, mean preoperative QoL score increased from 5.5 to 7.9 (P < .001), and mean difference between the mean circumferences of the affected and healthy limbs decreased from 4.3 ± 1.3 to 2.5 ± 1.3 cm, showing improvement of swelling after surgery (P < .01).

CONCLUSION

This technique allowed to preoperatively map UL lymphatics even if diffuse DB was present.

Practicality of the Lower Extremity Lymphedema Index: Lymphedema Index Versus Volumetry-Based Evaluations for Body-Type-Corrected Lower Extremity Volume Evaluation

BACKGROUND

Volume measurement is one of the most commonly used methods for lower extremity lymphedema (LEL) evaluation because of its objectivity. However, volume comparison between different patients with different body types may be inappropriate because body-type difference seems to significantly affect leg volume (LV).

METHODS

Twenty-seven nonedematous legs of 27 unilateral LEL patients were evaluated. The LEL index was calculated using circumferences and body mass index (BMI), and LV was calculated using a summed truncated cone model. The BMI of the examinees was classified into 3 groups: low BMI (BMI < 20), middle BMI (BMI, 20-25), and high BMI (BMI > 25). The LEL index, LV, LV divided by body surface area (LV/BSA), and LV divided by BMI (LV/BMI) were compared with the corresponding BMI groups.

RESULTS

The mean (SD) LEL index was 218.6 (12.9), and the mean (SD) LV was 4081.3 (835.6) mL. Between the low-, middle-, and high-BMI groups, there were no significant differences in the LEL index [223.2 (11.4), 217.8 (13.3), and 214.6 (14.2), P > 0.5] or in LV/BMI [185.5 (9.2), 179.3 (11.3), and 175.7 (15.8) mL per kg/m, P > 0.3], whereas significant differences were seen in LV [3484.9 (366.0), 3924.4 (342.5), and 5387.7 (1038.4) mL, P < 0.001) and in LV/BSA [2404.3 (236.6), 2539.2 (141.4), and 3106.0 (460.8) mL/m, P < 0.001].

CONCLUSIONS

The LEL index and LV/BMI stayed constant regardless of BMI, whereas LV and LV/BSA significantly increased with increase in BMI. With simplicity of calculation, the LEL index would allow more practical body-type-corrected LV evaluation compared with volumetry-based evaluations.