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Ma et al. Plast Aesthet Res 2021;8:32 https://dx.doi.org/10.20517/2347-9264.2021.20 Page 3 of 8

[11]
classification of the International Society of Lymphology (ISL) .

ICG lymphography
We performed ICG lymphography preoperatively for all patients. In the single-point injection group
(control group), 0.1 mL ICG was injected subcutaneously into the first web space of each foot or the second
web space of the hand. In the multipoint injection group, if we could not observe a linear pattern, four
injection points were added in the lower limbs, including the medial and malleolus and the medial and
lateral knees, respectively, and two injection points in the lateral wrist and the medial elbow were added in
the upper limbs. On the contrary, we injected ICG at only one site if we could find a good linear pattern in
both the lower leg and the thigh or both the forearm and the upper arm with the first injection. Therefore,
some of the patients in this group had only one injection. The number of injection sites was increased to
ensure that a sufficient number of linear lymphatic drainage images could be found. After injection, images
of the lymphatic drainage were observed using an infrared camera system and marked on the patient’s skin
[Figure 1]. The selection of the incision was based on the linear pattern of ICG lymphography. In the
control group, if no linear pattern of ICG was observed, the location of the incision was determined based
[12]
on the anatomical location of the lymphatic vessels, usually along the great saphenous vein . In the multi-
injection group, a linear pattern of ICG lymphography was usually observed.

The LVA procedure
All patients underwent LVA surgery under general anesthesia. After administering the anesthetic, the skin
was cut with a scalpel in the designed incision, looking for venules in the subcutaneous fat layer and
lymphatic vessels beneath the superficial fascia. Matching lymphatic vessels and blood vessels were found
and anastomosed end-to-end using 12-0 nylon thread. If matching lymphatic and blood vessels were not
found, or if the search took more than 40 min, the incision was abandoned and a new incision was
performed and the process started again. We anastomosed the upper limb in three places and the lower
limb in four places.

Evaluations and statistical analysis
The time of each operation and the number of incisions were recorded. Preoperative and postoperative
[1]
evaluation included the change in circumference of the affected limb . We collected the sum of the
circumference of six points of lower limbs (dorsal of foot, ankle, lower edge of patella 10 cm, upper edge of
patella 10 cm, upper edge of patella 10 cm, and upper edge of patella 20 cm) and the sum of the
circumference of the four points of the upper extremity (dorsal hand, wrist, elbow, and 10 cm above elbow)
before and six months after surgery. Each item related to the surgical results and the patients was compared
2
between the control group and the multi-injection group using the Student’s t-test or the χ test. The level of
statistical significance was set at P < 0.05.

RESULTS
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 patients’
characteristics are shown in Table 1. The average age was 56.3 years old (range: 45-67 years old). All patients
were female. There were 15 cases of upper extremity lymphedema and 27 cases of lower extremity
lymphedema. The average lymphedema duration was 116.5 months (range: 13-313 months). For both
groups, the follow-up was six months.