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Page 4 of 8 Ma et al. Plast Aesthet Res 2021;8:32 https://dx.doi.org/10.20517/2347-9264.2021.20

Table 1. Characteristics of the patients
Total Multi injection Control P
Number of patient 42 25 17
Age (year) Average (range) 56.3 (45-67) 55.6 (45-67) 56.8 (47-67) 0.491
Sex Female 42 25 17
Male - - -
The number of lymphedema limbs Upper 15 9 6
Lower 27 16 11
Lymphedema duration (months) Average (range) 116.5 (13-313) 112.9 (13-313) 121.8 (21-312) 0.691
ISL classification 1 12 6 6
2 18 11 7
3 12 8 4

ISL: International society of lymphology.

In the multi-injection group, the upper limbs were injected with ICG 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 average number of incisions in the
upper limbs of the two groups was four (range: 3-6 in the control group and 3-5 in the multi-injection
group) and the lower limb was five in both groups (range: 4-8 in the control group and 4-6 in the multi-
injection group). The surgical duration for the upper limb in the control group was 269 ± 47 min (P = 0.017)
and in the multi-injection group was 218 ± 27 min. The surgical time for the lower limb in the control group
was 363 ± 40 min and in the multi-injection group was 322 ± 55 min (P = 0.035) [Table 2].

In the control group, the mean preoperative and postoperative circumferences of the upper limbs (sum of
four points) were 115.4 ± 3.2 and 110.8 ± 3.3 cm(P = 0.033) and of the lower limbs (sum of six points) were
246.0 ± 9.8 and 239.2 ± 9.9 cm, respectively (P = 0.118) .In the multi-injection group, the mean preoperative
and postoperative circumferences of the upper limbs (sum of four points) were 116.3 ± 4.8 and 108.2 ± 4.0
cm (P = 0.001) and of the lower limbs (sum of six points) were 248.7 ± 7.9 and 236.2 ± 7.8 cm, respectively (
P < 0.05). 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) [Figure 2].

DISCUSSION
In this study, compared with the control group, we could find more effective lymphatic vessels by multi-
injection of ICG before LVA. This may significantly improve the results of surgical outcome. According to
the results of this study, the indications of LVA may be expanded and more patients may benefit from this
low-invasive surgery.

ICG imaging can detect lymph vessel located up to 1-2 cm below the skin surface. Normal ICG
lymphography shows superficial lymph vessels as white lines on a screen dynamically. ICG lymphography
can show lymph vessels immediately after injection of ICG. When images of lymph vessels are unclear, the
ICG injection site should be massaged manually .
[13]
Sometimes, the injury of a lymphatic vessel starts at the distal side of the limb and the contrast agents
cannot enter the lymphatic vessels, so the lymphatics cannot be seen when these substances are injected into
the dorsal side of the foot or hand . ICG lymphography findings are largely classifiable into two patterns:
[14]
linear pattern and dermal backflow pattern . Unfortunately, many patients present with dermal backflow
[15]
pattern at their initial visit. In clinical work, we inject additional ICG into the medial and lateral side of the