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Page 2 of 5 Chen et al. Plast Aesthet Res 2023;10:5 https://dx.doi.org/10.20517/2347-9264.2022.117

lymphedema, lymphatic stasis and unfavorable pressure gradients may prevent visualization of healthy
lymph vessels even when they are present. Based on our observation, the classic ICG injection technique has
resulted in many patients being unnecessarily declared as poor LVA candidates, due to the scant
[5]
visualization of lymph vessels. In this article, we share our ICG lymphographic mapping technique , which
is time-tested and has helped us achieve successful LVA reconstruction in many difficult cases.

TECHNIQUE
The procedure begins with intradermal injection of two to three dorsal web spaces of the ipsilateral
hand/feet using 0.1 cc of 0.25% indocyanine green per injection point. This is followed by a gentle massage
at the injected sites for 2 minutes. A near-infrared, fluorescence camera system is then used for visualizing
the real-time spread of ICG. The course of the identified lymphatic vessels is then marked on the skin.
Another row of ICG injections is given at the ankle/wrist level and the resultant change in lymphatic
patterns is marked. This process is repeated at 15 cm (10 cm in upper limb) intervals along the extremity till
the popliteal fossa/ cubital fossa is reached. Each level includes a row of multiple injection points, 3 to 4 cm
apart, along the anterior and medial part of the limb circumference. The lymphatics pattern generated from
these different injection levels is marked with different colors in Figure 1 to distinguish their origins. This
distal-to-proximal sequential ICG injection technique (DOPSIT) is demonstrated step by step in
Supplementary Video.

DISCUSSION
In our lymphedema clinic, we most commonly hear from our patients, “I want LVA. I don’t want any other
surgery!” The popularity of LVA stems from its capability to treat a bothersome, disabling condition with
minimal invasiveness. Indeed, in comparison to vascularized lymph node/vessel transfers (VLNT/VLVT),
LVA is conceptually benign and is free of the risk of causing donor-site lymphedema . Interestingly, LVA’s
[3]
popularity among patients is not replicated among surgeons. In North America, VLNT remains the most
commonly offered/performed lymphedema reconstruction. Why?

Many factors go into successful and efficacious LVA, including but not limited to patient selection,
preoperative optimization, proficiency in supermicrosurgery, number of anastomoses, choice of
anastomotic configuration, and postoperative care . Among these, the ability to identify all available
[6,7]
lymph vessels is crucial. After all, without the “L”, there would be no LVA. LVA has been our go-to
technique for all cases of fluid-predominant lymphedema. After overcoming our learning curve, we have
found LVA to be technically straightforward, effective, and gratifying for both the patient and the surgeon.
One of the keys to our procedural success is the ICG lymphographic mapping using DOPSIT. This
technique allows us to identify more viable lymph vessels than achievable with the classic injection
technique, leading to the creation of more functioning lymphatic drainage pathways in both upper and
lower limbs.

In severe disease, unfavorable lymphatic pressure gradients can be such that, despite the use of DOPSIT, no
lymph vessels are detectable. In this challenging scenario, the lymph vessels can usually be found by making
incisions over veins mapped using an infrared vein finder. This technical trick takes advantage of the
anatomic fact that superficial lymphatic anatomy loosely approximates that of superficial venous anatomy.
In the unfortunate scenario of failure to image both the lymph vessels and the superficial veins, the lymph
vessels can still be uncovered with the so-called “blind/anatomic” approach, based on a detailed knowledge
of the superficial lymphatic system - how the lymph vessels are distinctly clustered in certain anatomic
segments .
[5,8]