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Page 2 of 8 Ma et al. Plast Aesthet Res 2021;8:32 https://dx.doi.org/10.20517/2347-9264.2021.20

Results: In the multi-injection group, we injected ICG into the upper limb at an average of 2.2 sites (range: 1-3
sites) and the lower limb at an average of 3.2 sites (range: 1-5 sites). The circumference change of upper limbs in
the control group was -3.95% ± 1.34% and in the multi-injection group was -6.96% ± 0.88% (P < 0.05). The
change in circumference of lower limbs was -5.01% ± 2.2% in the multi-injection group and -2.33% ± 1.77% in the
control group (P = 0.003). The mean surgical duration was significantly shortened in the multi-injection group (P <
0.05).

Conclusion: By injecting ICG into multiple sites of the affected limbs, we could detect more functional lymphatic
vessels during LVA, which was helpful for achieving a successful surgical result.

Keywords: Lymphedema, indocyanine green, indocyanine green lymphography, multipoint injection,
lymphaticovenular anastomosis

INTRODUCTION
[1]
Lymphedema is a disease in which lymphatic fluid accumulates in the skin or subcutaneous tissue . It
usually occurs during tumor surgery, lymph node dissection, or postoperative radiotherapy. The
accumulation of protein-rich lymphatic fluid in the skin leads to the infiltration of immune cells and
inflammatory response, resulting in chronic inflammation of the subcutaneous tissue. The end results of
[2]
chronic inflammation are fatty hypertrophy and fibrosis of lymphatic vessels and connective tissue .

Lymphaticovenular anastomosis (LVA) is a surgical procedure for the treatment of lymphedema. Because
LVA is a minimally invasive procedure, we use LVA as the first choice of surgery. It can effectively reduce
the incidence of limb mass, cellulitis, and other complications associated with lymphedema . However,
[3-5]
the standard for LVA has not been established regarding the location, number, and pattern of
[6]
anastomoses . To date, there have been no reports of worsening conditions caused by LVA surgery, even
when the procedure was unsuccessful.

Indocyanine green (ICG) is a fluorescent anthocyanin dye that remains in the blood and lymphatic vessels
due to its binding to plasma proteins. Now, ICG lymphography is a common method of LVA examination,
which is suitable for preoperative, intraoperative, and postoperative evaluation of lymphatic drainage . It
[7-9]
has the unique ability to reveal lymphoid structural disorders and is highly accurate in the assessment of
[10]
lymphoedema and lymphoid drainage disorders . However, when there is no adequate lymphatic function
in the distal limb, information about the location of the lymphatic vessels is unobtainable, even if lymphatic
vessel function is adequate in the proximal limb. To overcome this limitation, we propose multipoint
injection ICG lymphography.

We studied LVA using multipoint injections of ICG. The multipoint injection method could find more
functional lymphatic vessels preoperatively, thus improving the successful patency rate of LVA surgery and
shortening the operative time. The purpose of this study was to validate the efficacy of LVA combined with
multipoint ICG lymphography in the treatment of lymphedema.

METHODS
Patients
This study was a prospective study approved by the ethical committee of Xi’an Central Hospital. In total, 42
patients were treated between June 2018 and July 2020, of whom 17 patients received single-point injection
of ICG (6 cases of upper limbs and 11 cases of lower limbs) and 25 patients received multipoint injection of
ICG (9 cases of upper limbs and 16 cases of lower limbs). The severity of lymphedema was diagnosed by the