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Page 2 of 11 Hara et al. Plast Aesthet Res 2023;10:42 https://dx.doi.org/10.20517/2347-9264.2023.11

INTRODUCTION
Surgical treatments for lymphedema include lymphaticovenous anastomosis (LVA) , lymph node
[1-3]
[4,5]
[6]
transfer , liposuction , and excisional surgery . Among these, LVA is a minimally invasive surgery that
[7]
can be performed under local anesthesia . Anastomosing a lymph vessel with accumulated lymph fluid into
[8]
a vein is a bypass surgery that allows the lymph to flow back to the heart via the vein. LVA reduces the
circumference of the affected limb, softens the skin of the affected limb, and reduces the frequency of
cellulitis [9,10] . Lymphangiosclerosis is known to occur in limbs with lymphedema, and LVA has traditionally
been indicated for early-stage lymphedema in which well-functioning lymphatic vessels remain [11-14] .
However, in recent years, lymphatic function examinations have developed rapidly, and multi-point
indocyanine green (ICG) lymphography (originally reported as multi-lymphosome ICG
lymphography) [15-19] , photoacoustic ICG lymphography [20-22] , lymphatic ultrasound [23-30] , and ultra-high
frequency ultrasound [31-33] , have been developed, in addition to conventional ICG lymphography or
lymphoscintigraphy [32-38] .

We are actively performing multi-point ICG lymphography and lymphatic ultrasound as a preoperative
examination for LVA, which has improved surgical outcomes and made it possible to perform LVA even
for advanced lymphedema , which was not indicated before. Lymphatic ultrasound is particularly useful
[2]
and can be widely used for preoperative examination [23-25] , diagnosis of lymphedema [28-30] , and evaluation of
physiological and pathological changes in lymphatic vessels . After LVA, the patients resume the same
[27]
compression therapy as before from postoperative day 1. The same compression therapy is continued for six
months postoperatively to accurately evaluate the effect of LVA. Hamada and Kaciulyte reported that LVA
can reduce or discontinue compression therapy [39,40] .

In this Technical Note article, we comprehensively describe lymphatic function examinations that we have
developed so far. The institutional ethics committee approved the study and written informed consent was
obtained from each patient (approval number: R03-04).

MULTI- POINT ICG LYMPHOGRAPHY
Multi-point ICG lymphography is usually performed as a preoperative examination for LVA. The concept
[41]
of “lymphosome” was proposed by Suami to explain the lymphatic territory of the whole body . We
slightly revised the territories and injected ICG at three points: the first web space, the proximal point of the
lateral malleolus, and the lateral midline point at the level of the superior border of the patella [Figure 1].
Each injection point was located in the saphenous lymphatic area, lateral calf lymphatic area, and lateral
thigh lymphatic area.

In conventional ICG lymphography, we injected ICG only at the distal end of the limbs, first web space, and
around the Achilles tendon. In this method, only lymphatic vessels passing through the distal injection
point are enhanced. Moreover, when the lymphatic vessels around the injection point were severely
damaged, no lymphatic vessels were found.

With multi-point ICG lymphography, we can find a greater number of lymphatic vessels than with
conventional ICG lymphography or lymphoscintigraphy, and the surgical result improves [15,16] . In addition,
multi-point ICG lymphography sometimes detects lymphatic dysfunction, which cannot be observed on
lymphoscintigraphy .
[30]