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

that occurs in 20% of patients, and up to 33% when radiotherapy also is used [26,27] .

Farkas’s systemic review shows that conservative management was found to be effective in 38/40 of low
output leakage cases (< 500 mL/day), while surgical intervention was necessary in 7/9 of high output leakage
[6]
cases (> 500 mL/day) . His review offers a therapeutic algorithm based on chyle leakage output per day.

Our experience shows that volume output alone was not enough to determine the best treatment approach,
[6]
as was offered by Farkas’s algorithm . First, surgical reexploration and the following intensive conservative
treatment could not solve the chyle leakage of our patient. As a consequence, we think that the right
therapeutic approach should rely mostly on the dynamics of the leakage output, as offered by Delaney’s
algorithm for the treatment of chyle leakage for head and neck surgery .
[28]

From Farkas’s systemic review, we learn that the diagnosis of chyle leakage is usually given by sampling the
[6]
milky fluid collected by the postoperative drain . Diagnosis could also be made by aspirating a new
postoperative swelling [29-32] . In the case of diagnosis made by collecting chyle from the drain, we suggest
initiating a conservative management for the next 3-4 days and to observe the chyle output dynamics. Early
surgical reexploration is suggested when the output volume does not decrease.

Rarely, the diagnosis is made by aspirating a new postoperative swelling [29-32] . In those rare cases, the chyle
leakage was treated conservatively and had stopped on average 35 days after its diagnosis. Thus, with the
goal of shortening the duration of treatment, we suggest proceeding to a local wound surgical treatment.
Conservative management should be continued for another 3 days after the surgical treatment and chyle
output dynamics should be monitored closely.

When there is no decrease in volume output and before proceeding to a thoracic duct focused approach, we
would like to offer the exclusion of a peripheral component to the leakage.

ICG lymphography, a low morbidity and simple diagnostic tool, could be performed for demonstrating the
lymphatic flow from the distal arm to the direction of the axilla. Diagnosis of lymphorrhea can be made if
ICG, injected into the finger web, appears to flow in the drain. In this case, performing LVA in the proximal
arm could decrease lymphatic leakage to the wound bed, thus ameliorating wound healing conditions and
decreasing the total volume leakage output.

Exclusion of lymphorrhea (peripheral component) or no decrease in leakage output after performing LVA
suggests that the main origin of leakage is the thoracic duct (central component). Inguinal intranodal
lymphangiography can demonstrate this leakage. The leaking branch of the thoracic duct could be
demonstrated and embolized proximally by using percutaneous transabdominal catheterization of the
cisterna chyli.

Lastly, if there is no improvement after those interventions, fasting and TPN could be considered for further
decreasing lymphatic flow from the intestines. TPN is reserved for the most difficult cases due to its
association with an increased rate of infections, venous thrombosis, and hepatic and gastrointestinal
[33]
complications . Further surgical intervention should be evaluated by a multidisciplinary team.

After every intervention, we suggest continuing conservative management and monitoring chyle output.
The drain should be removed when the output drops below 30 mL/day or after 5-7 days of a consecutive
[7]
output decrease .