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Ma et al. Plast Aesthet Res 2021;8:32 https://dx.doi.org/10.20517/2347-9264.2021.20 Page 5 of 8

Table 2. Surgical results
Total Multi injection Control P
Number of injection per limb Upper 2.2 (1-3) 1
Average (range)
Lower 3.2 (1-5) 1
Number of incision per limb Upper 4 3.7 (3-5) 4.5 (3-6) 0.117
Average (range)
Lower 5 4.6 (4-6) 5.5 (4-8) 0.058
Number of LVA per limb Upper 3 3 3
Lower 4 4 4
Operation time per patient (min) Upper 238 (180-324) 218 (180-260) 269 (196-324) 0.017
Lower 339 (265-450) 322 (265-405) 363 (286-450) 0.035
LVA: Lymphaticovenular anastomosis.

ankle and the knee, when we cannot find a linear pattern after injecting ICG into the dorsum of the foot. In
this study, we could find more lymphatic vessels and the surgical results were better than the results in the
control group. Preoperative detection of functional lymphatics is an important aspect of a successful LVA.
For this purpose, we applied multi-injection ICG to detect the lymphatic vessels.

[16]
Mihara et al. reported that lymphatic vessels of the ectasis type was most effective for LVA. In this study,
the proportion of the ectasis type lymphatic vessels in the multi-injection group was significantly higher
than that in the control group, indicating that more ectasis type lymphatic vessels could be detected by
multi-injection ICG. Although the number of anastomoses was similar between the two groups, more
Ectasis type lymphatic vessels were found in the multi-injection group, which could explain the improved
surgical outcomes. Therefore, injecting ICG into the distal part of the extremities as a preoperative
examination for LVA was insufficient.

In this study, the surgical duration of the limb was significantly shortened in the multi-injection group.
Based on the linear pattern of the ICG lymphogram, we determined the surgical incision. When we could
not observe a linear pattern, we made an incision along the anatomical location of the lymphatic vessels,
which was usually along the pattern of the great saphenous vein. However, it was not always possible to
accurately detect the patient’s lymphatic vessels, and thus more time was sometimes required to find the
lymphatic vessels during the surgery. By the multi-injection method, we were able to locate more linear
patterns than in the control group. This technique could offer significant help to the surgeon in rapidly
locating the lymphatic vessels during surgery.

Multiple injections of ICG lymphography could help us find more functional lymphatics than when using
conventional ICG lymphography. We were sometimes able to observe linear patterns in the limb when the
ICG was injected into more sites, even if we could not see the spread of the ICG injected into the dorsum of
the hand or foot.

To ensure the same observation time between the two groups, the limitation of this study was that the
follow-up time was not long enough. Based on our experience, lymphedema usually continues to improve
in patients who improve after six months. Prolonged postoperative follow-up is necessary to assess the long-
term effects of LVA.

In conclusion, multipoint injection ICG in lymphography could effectively improve the efficacy of LVA. It
could help us to detect more functional lymphatic vessels suitable for anastomosis. The proportion of ectasis
type lymphatic vessels used for anastomosis in the multi-injection group was significantly higher, which