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Lasso. Plast Aesthet Res 2020;7:30 I http://dx.doi.org/10.20517/2347-9264.2019.75 Page 3 of 12

and uninvolved limb at all points. The circumference difference was registered at first visit and at each
postoperative visit after LVA. Results were considered stable and registered for analysis at the one-year-
postoperative visit after surgery.

The clinical examination also included a record of complications, episodes of cellulitis and an enquiry
about subjective symptoms. Subjective perception of the disease was evaluated with a patient survey
[6]
that consisted of four questions utilizing a five-point Likert-type scale and a fifth enquiry about overall
treatment satisfaction (Satisfaction with limb weight, appearance, firmness, ability to perform daily
activities: scores ranging from 1-5, being 5 the highest score; and would you undergo surgery again? yes/
no). The questionnaire was developed at our center and has been standardized for use in all lymphedema
patients since 2008.

Surgical protocol (LVA-ICG)
TM
In the operating room, ICG (VERDYE ; Diagnostic Green GmbH, Aschheim-Dornach, Germany) was
injected intradermally into the first and fourth web spaces (0.1 mL per injection of a 25 mg/mL solution
mixed with 5 mL of water for injection), 15 minutes later, circumferential fluorescent images of the
TM
lymphatic drainage channels were obtained using an infrared camera system (Photodynamic Eye, PDE ;
Hamamatsu Photonics K.K., Hamamatsu, Japan). Lymphography patterns were described at this moment.
Linear patterns or patterns that showed dynamic drainage of ICG were marked on the skin. ICG fluorescent
images were obtained both before and during ICG-SL surgery and at every year postoperatively. Findings

were labeled according to Yamamoto’s dermal backflow classification and contrasted with postoperative
SPECT-CT/lymphoscintigraphy results. It was found that this ICG lymphangiography staging system had
[7]
a significant correlation with the clinical stage of lymphedema . In the proximal part of the affected limb,
dermal backflow patterns were more frequently found than linear patterns. The dermal backflow pattern is
further divided into splash, stardust and diffuse patterns.

LVAs were performed under general anesthesia in all cases, with specific material and 12/0 monofilament
sutures, under microscope magnification. Anastomoses were performed end-to-end and end-to-side,
depending on the availability of recipient veins. Skin closure was achieved with superficial non-absorbable
sutures (4/0) without subcutaneous sutures.

Postoperative care
Oral antibiotics were prescribed for five days after surgery. Patients wore a soft non-elastic bandage that
was replaced every 3 days for 3 weeks, under surgeons’ supervision. Subsequently, from the fourth week,
customized compression sleeves were placed for three months. Lymphatic drainage was performed twice a
week during this period. After drainage, patients wore elastic stockings as instructed. On the other hand,
conservative therapy prior to LVA consisted of lymphatic drainage that started three weeks before (twice
per week).

Nuclear medicine
Lympho-SPECT/CT was performed in all subjects at the first consultation and at every year after surgical
intervention. Lymphography was done with 46 MBq Tc-99m of nanocolloidal human albumin (Nanocoll,
c
GE Healthcare ) injected into the subcutaneous plane at the second web space in each limb (both healthy
and affected) after dilution in 0.15 mL of 0.9% sodium chloride. As 85% of colloids are smaller than 80 nm,
a 30-gauge needle was required. The interval between injections was less than 30 s.

As patients may have severe alteration of lymphatic flow due to fibrosis or ectasia, they were asked to walk
around or elevate the arms for 30 min before obtaining planar images. Conventional lymphoscintigraphy
was then performed: anterior and posterior planar images from shoulder to hand (hip to foot) were