Page 9 - Read Online

Liang et al. Plast Aesthet Res 2023;10:71 https://dx.doi.org/10.20517/2347-9264.2023.81 Page 3 of 13

Preoperative imaging and evaluation is crucial. Having a single modality that can accurately assess both
lymphatics and subcutaneous veins in real time can allow pertinent placement of skin incisions at the most
suitable locations, thus greatly improving the chances of success of LVA. The aim of this study is two-fold:
(1) to describe the use of ultrasonography, with ICG lymphography as an adjunct, to reliably map suitable
lymphatics and subcutaneous veins and successfully perform LVA surgery, even in cases of advanced upper
limb lymphedema and (2) to evaluate the results of LVA surgery in this patient cohort.

METHODS
This was a retrospective study conducted at the Division of Plastic and Reconstruction Surgery, Department
of Surgery, E- DA Cancer Hospital, Kaohsiung City, Taiwan, China. Between November 2019 and August
2023, all patients with upper limb lymphedema were identified. Those who did not have breast cancer-
related lymphedema (BCRL), who did not undergo LVA surgery, or those with mild disease (International
Society of Lymphology grade (1) were excluded from the study.

Patients’ demographic data and operative information were collected. Preoperative sonographic detection
and characterization of lymphatics and veins were corroborated with intraoperative findings to determine
the accuracy of ultrasonography as an imaging modality. For an objective assessment of the effects of LVA,
the arm circumferences of patients were measured at four points: at the wrist, 10 cm below the elbow, at the
elbow, and 10 cm above the elbow. These circumferences were also added together to obtain a Total
Circumference (TC) value for each patient. These measurements obtained preoperatively were compared
against those made at 1 month and 3 months after surgery. Statistical analysis of these two sets of results was
performed using the paired sample t-test.

ICG lymphography
ICG lymphography was performed on the evening before surgery. Briefly, ICG was diluted to a
concentration of 2.5 mg/mL, and injected intradermally into the web spaces of each patient’s hand and at
the wrist. Several minutes after the injection, ICG uptake within functional lymphatic collecting vessels was
®
detected using the Mitaka Hamamatsu pde-neo II system. As ICG traveled proximally, its course was traced
and marked on the skin. ICG lymphography was repeated the next morning before surgery to reaffirm
previous markings and chart new tracts that were missed. Areas with dermal backflow patterns were also
marked.

Ultrasonography
Ultrasonography was performed preoperatively in all patients using a commonly available ultrasound
machine, Sonosite X-Porte ultrasound, with 18 MHz and a flat probe. The depth of view was adjusted to
®
3.1 cm to centralize the view on the subcutaneous fat layer. Color Doppler mode was used, with the flow
detection level set at 3 to -3 cm/s, corresponding to the average blood flow rate in subcutaneous veins. The
probe was placed axially on the lymphedematous limbs, perpendicular to the expected long axis of the
lymphatics and veins. Care was taken to minimize the pressure of the probe on the skin to avoid artificial
deformation of the underlying vessels. The first regions to be assessed were those where ICG lymphography
demonstrated linear patterns. Thereafter, if the limb only revealed dense dermal backflow patterns,
attention was turned to areas more commonly showing a higher density of lymphatics, such as the dorsal
and ventral surfaces of the wrist, ulnar aspect of the forearm, and medial aspect of the upper arm.
Assessment of both lymphatic vessels and subcutaneous veins was performed and the planned skin incisions
were placed strategically.