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Chen et al. Plast Aesthet Res 2023;10:5 Plastic and
DOI: 10.20517/2347-9264.2022.117
Aesthetic Research

Technical Note Open Access

Distal- to- proximal sequential ICG injection
technique (DOPSIT) for lymphatic vessels mapping

Wei F. Chen, Sonia Kukreja Pandey

Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
Correspondence to: Prof. Wei F. Chen, Professor of Plastic Surgery, Head, Regional Microsurgery & Supermicrosurgery, Co-
Director, Center for Lymphedema Research and Reconstruction, Department of Plastic and Reconstructive Surgery, Cleveland
Clinic Foundation, 9500 Euclid Avenue, Desk A60, Cleveland, OH 44195, USA. E-mail: weifchen@hotmail.com
How to cite this article: Chen WF, Pandey SK. Distal- to- proximal sequential ICG injection technique (DOPSIT) for lymphatic
vessels mapping. Plast Aesthet Res 2023;10:5. https://dx.doi.org/10.20517/2347-9264.2022.117

Received: 10 Oct 2022 First Decision: 11 Jan 2023 Revised: 30 Jan 2023 Accepted: 17 Feb 2023 Published: 21 Feb 2023

Academic Editors: Matthew Iorio, Melissa B. Aldrich Copy Editor: Ying Han Production Editor: Ying Han

Abstract
Supermicrosurgical lymphaticovenular anastomosis (LVA) is the most sought-after procedure among lymphedema
patients. However, the same enthusiasm is currently not shared among lymphedema surgeons due to the
lackluster results of LVA. The common unfavorable experience with this famed procedure is at least partially
caused by the difficulty in finding the lymph vessels. We share our time-tested indocyanine green-based lymph
vessel mapping technique, which has helped us establish LVA as our procedure for all fluid-predominant
lymphedema.

Keywords: ICG lymphography, ICG flow, linear patterns, lymphatic mapping, multipoint injection, multilevel
injection, advanced lymphedema

INTRODUCTION
With recent technical breakthroughs, supermicrosurgical lymphaticovenular anastomosis (LVA) is no
[1-4]
longer limited to early lymphedema . However, performing LVA in late disease is frequently challenging
due to difficult lymphographic identification of the functioning lymph vessels. Classically, indocyanine
green (ICG) lymphographic mapping is performed with 2 to 3 injections of the fluorophore in hands and
feet. The “linear” patterns observed immediately post-injection are identified as targets for LVA. In late

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
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