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Page 4 of 11 Drobot et al. Plast Aesthet Res 2021;8:30 https://dx.doi.org/10.20517/2347-9264.2021.19

evidence of axillary leakage. The distal end of the thoracic duct branched into a small collateral lymph vessel
that was draining in the direction of the neck. No clear leakage was detected, and, with the idea that the
small collateral lymphatic vessel might be the source of the chylous leakage, the distal end of the thoracic
duct was embolized by placing two "Tornado Embolization Coils" (COOK MEDICAL LLC, USA) and using
acrylic glue, "Glubran 2" (GEM Srl, Viareggio, Italy) [Figure 3]. Following the procedure, TPN was
reinitiated. Initially, the leakage decreased significantly, but, within few days, it stabilized on 270 mL per
day.

On POD 40, TPN was discontinued. Up to this day, the patient had lost about 6 kg (10% of her initial body
weight). Indocyanine green (ICG)-based lymphography of the left hand was performed by injecting 0.2 mL
(25 mg/10 cc) "Verdye" (Diagnostic Green LLC, Germany) into the finger web. The imaging demonstrated
lymphatic vessels directing towards the axillary region and the wound bed. About 5 min after the injection,
ICG started to flow into the drain, proving that lymphatic leakage from the left hand had also contributed to
the chyle leakage volume [Figure 4]. This diagnostic tool demonstrated the contribution of a peripheral
component to the total leakage output volume. Four end-to-end lymphaticovenular anastomoses (LVA) in
the proximal left arm were performed, based on the ICG imaging of the main lymphatic pathways leading
to the wound bed and drain [Figure 5]. The patency of the anastomoses was demonstrated using SPY
fluorescence imaging system (Stryker Corp/Novadaq Technologies, Kalamazoo, Mich) fluorescence
imaging system [Figure 6]. Exploration of the operative wound followed by debridement, placement of a
new drain, and insertion of 2 mL of fibrin glue, "Tisseel" (Baxter Healthcare Corporation, USA). In the
evening, the patient started P.O. nutrition. On the next day, the lymphatic drain summed to 50 mL. The
patient was discharged to home the day after with the drain, presenting no further drain leakage. The drain
was removed on POD 47.

DISCUSSION
Chyle is a milky substance containing a high content of lipids, proteins, and lymphocytes. It is derived from
the intestines during digestion and carried by the lymphatic system . The thoracic duct drains lymph from
[1]
the entire left body and the right side below the diaphragm. Usually, it enters the venous system at the level
of the left brachiocephalic vein. During surgery, iatrogenic injuries to the thoracic duct could lead to
[2]
chylous leakage, especially due to aberrant anatomy .

Owing to the remote anatomical location of the thoracic duct, post-axillary surgery chyle leakage is a rare
[3-5]
complication, with an incidence of 0.36%-0.68% . Chyle leakage complication is more commonly seen in
head and neck surgery; however, because of its complexity and the lack of clinical trials, there is no
consensus regarding the algorithm of management. Due to the obvious milky appearance of chyle, the
current literature assumes that the main origin of the leaking fluid is the thoracic duct. Therefore, clinical
experience focuses on reducing flow in the injured thoracic duct and local wound therapy. The treatment
divides between conservative and surgical approaches.

The conservative management includes the following measures:

(1) Suction drain is traditionally placed during the final steps of axillary lymphadenectomy for preventing
[7]
the accumulation of fluids (seroma) in the potential dead space . This enables favorable wound healing
conditions.

(2) Local pressure dressing: Applying external pressure on the wound bed may compress the leaking
lymphatic vessels .
[8]