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Page 6 of 13 Liang et al. Plast Aesthet Res 2023;10:71 https://dx.doi.org/10.20517/2347-9264.2023.81

Figure 4. A: Upper (side to end, suture with Keisei 11-0, 50 μ needle, 5R23 11-0N), and lower anastomoses (end to end, suture with
Keisei 12-0, 50 μ needle, 5R23 12-0N) showed no blood backflow into lymphatic vessels; B: Intraoperative ICG lymphography shows
patency of the microanastomoses with a good flow of lymphatic fluid into the venules. The red circle outlines the valve of the vein.

bandages at pressures of 40 mmHg was performed for the first 3 months. This was subsequently converted
to pressure garments that usually apply 25 mmHg of pressure, and these were worn from 3 to 6 months
postoperatively. After 6 months, pressure garment use was gradually terminated. Thereafter, the condition
of most patients remained stable; some were unable to completely stop wearing pressure garments or
wearing them in an on-and-off manner depending on their lifestyle requirements.

RESULTS
Fifty-four patients with upper limb lymphedema were identified, of which 51 had BCRL and fulfilled the
inclusion and exclusion criteria. Ten patients were excluded because of incomplete data from missed follow-
ups during the COVID-19 pandemic lockdown, resulting in a cohort of 41 female patients. Their
background characteristics are summarized in Table 1. The average age of the patients was 62.6 years, with a
range of 47 to 80 years. The median body mass index (BMI) of the patients was 24.2 kg/m , with a range of
2
2
20 to 31 kg/m . The average duration of lymphedema was approximately 11.82 years (range: 5-25 years). Of
the 41 patients, 40 underwent axillary lymphadenectomy. All 41 patients received adjuvant radiotherapy,
and 38 received adjuvant chemotherapy. According to the International Society of Lymphology (ISL)
staging system, 5 patients had grade 2a, 33 patients had grade 2b, and 3 patients had grade 3 lymphedema.
The average follow-up period for the patients was 12.1 months, ranging from 5 to 24 months.

Among the 41 patients, 155 incisions were made and 212 LVA procedures were performed. Out of these 212
LVAs, 133 underwent preoperative sonographic detection of lymphatic vessels that correlated with
intraoperative findings, yielding a success rate of 62.7%. Likely reasons for this low rate include the small
size of the upper limb lymphatics and advanced staging of lymphedema in this patient cohort. For anti-
reflux veins, 196 out of 212 LVA procedures showed a good correlation between preoperative sonographic
detection and intraoperative findings, with a success rate of 92.4%.

For the circumference at the wrist, 10cm below elbow, elbow, and 10cm above elbow, the mean
measurements taken preoperatively were 18.86 cm, 27.79 cm, 29.75 cm, and 33.77 cm, respectively. At the 1-
month follow-up, the corresponding mean measurements were 17.14 cm, 24.86 cm, 26.91 cm, and 30.50 cm,
showing improvements of 9.12%, 10.54%, 9.54%, and 9.70%, respectively. At the 3-month follow-up, the
mean measurements were 16.59 cm, 24.28 cm, 26.55 cm, and 30.05 cm, with an improvement of 12.02%,
12.63%, 10.73%, and 11.02%, respectively, compared to preoperative results [Figures 5 and 6]. These
differences were all statistically significant (P < 0.0001).

To track the relative improvement for each individual patient, their circumferences at the four measurement
points were also added to obtain a Total Circumference (TC) figure. Preoperatively, the TC ranged from 89-
135 cm (mean 109.46 cm). At 1 month after surgery, the TC ranged from 83.5-129.5 cm (mean 98.74 cm),
and at 3 months after surgery, the TC ranged from 80.5-128 cm (mean 96.55 cm). When comparing the