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Page 2 of 13 Liang et al. Plast Aesthet Res 2023;10:71 https://dx.doi.org/10.20517/2347-9264.2023.81

preoperative circumference at the wrist, 10cm below elbow, elbow, and 10cm above elbow were 18.86 cm, 27.79
cm, 29.75 cm, and 33.77 cm, respectively. The mean measurements improved at 1 month correspondingly to 17.14
cm, 24.86 cm, 26.91 cm, and 30.50 cm (9.12%, 10.54%, 9.54%, 9.70% improvement, respectively), and at 3
months to 16.59 cm, 24.28 cm, 26.55 cm, and 30.05 cm (12.02%, 12.63%, 10.73%, 11.02% improvement,
respectively). For each individual patient, their four measured circumferences were also added to obtain the Total
Circumference (TC). The TC ranged from 89-135 cm (mean 109.46 cm) preoperatively, 83.5-129.5 cm (mean
98.74 cm) 1-month post-op, and 80.5-128 cm (mean 96.55 cm) 3 months post-op. Compared to the preoperative
value, each patient had a TC decrease of 2.79%-20.35% (mean 9.80%) at 1-month post-op and 4.39-28.30%
(mean 11.80%) at 3 months post-op. These differences were all statistically significant (P < 0.0001).

Conclusion: Preoperative ultrasonography is a useful adjunct to detect lymphatic vessels and anti-reflux veins,
thereby increasing the chances of successfully performing LVA surgery even in cases of advanced upper limb
lymphedema. It can contribute to long-lasting outcomes.

Keywords: Advanced breast cancer-related lymphedema, lymphaticovenous anastomosis/bypass, upper limb
lymphedema, BCRL

INTRODUCTION
Secondary lymphedema of the upper limb is an unfortunate complication of breast cancer
lymphadenectomy and radiotherapy. Statistics from the World Health Organization showed that, in 2020,
2.3 million new diagnoses of breast cancer were confirmed in patients worldwide, making it the most
[1]
prevalent cancer globally. In this huge patient population, the incidence of lymphedema was 21% . Thus, a
staggering number of patients are affected by this chronic and debilitating condition.

Supermicrosurgical lymphaticovenous anastomosis (LVA) has emerged in the past two decades as a
[2-7]
mainstay of surgical treatment for refractory lymphedema . This physiologic procedure attempts to bypass
the lymphatic obstruction by draining the engorged lymphatic collectors into subcutaneous veins. LVA
surgery is well-tolerated and minimally invasive, requiring a small skin incision. It is crucial to plan the
location of this incision preoperatively so that both lymphatic collectors and subcutaneous veins can be
assessed.

Various modalities allow the mapping of lymphatic vessels preoperatively, including lymphoscintigraphy,
[8,9]
magnetic resonance lymphography, and fluorescence imaging . Of these, fluorescence imaging using near-
infrared light and indocyanine green (ICG) is arguably the most popular and clinically useful method,
allowing real-time imaging and mapping of lymphatics [10,11] . However, its limitations are apparent in severe
cases of lymphedema. The presence of stardust or diffuse ICG lymphography patterns in advanced
lymphedema may deter the consideration of LVA surgery, despite the potential presence of functional or
[12]
patent lymphatics in these areas . Furthermore, these overlying dense dermal backflow patterns mask the
lymphatics underneath and impair efforts to locate them accurately .
[13]

Ultrasonography for preoperative lymphatic mapping in LVA surgery is a new approach. Literature on the
pioneering works of surgeons in Japan details the ultrasonographic visualization of lymphatics of the lower
limb [14-17] . However, to our knowledge, there is no article available on ultrasonographic evaluation of
lymphatics in upper limb lymphoedema, where the lymphatics are smaller and more difficult to detect with
conventional means, especially in cases of advanced lymphoedema. Ultrasonography has the additional
benefit of being able to map subcutaneous veins, which is evident in its remarkable performance in cases of
difficult venous access [18-21] .