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Page 10 of 14 Calderwood et al. Plast Aesthet Res 2021;8:40 https://dx.doi.org/10.20517/2347-9264.2021.14

[17]
Lu et al. found that contrast-enhanced MRL identified the location of post-traumatic inguinal lymphatic
vessel leakage in 93.8% of patients studied, all of whom were reported to have successful surgical ligation of
the damaged vessel once it had been located. On conventional T2 MRI, these regions of high signal intensity
cannot be distinguished from other fluid-filled lesions, and therefore cannot be accurately confirmed as the
site of lymphatic vessel leakage.

MRL is useful in both identifying the condition of lymphatic vessels and assessing the patient’s response to
surgery by measuring the reduction in oedema, limb size, and dermal backflow [2,3,8,18,23] . Arrivé et al. found
[20]
that non-contrast MRL may be useful as an objective technique to analyse the post-operative results of
lymph node transplantation.

BENEFITS AND LIMITATIONS
Benefits
Not only is MRL widely recognised for having a higher spatial and temporal resolution than
lymphoscintigraphy, but it has many other benefits that contribute to its increasing popularity as an
imaging modality for the lymphatic system [2,7,11,18,21,24,25,30] . MRL utilises contrast uptake into lymphatic vessels,
transportation through the lymphatic system, and nodal uptake to give both high-quality anatomical and
functional assessments of the lymphatic drainage system in one process [2,3,7,11,15,18,19,23,25,27,34] . It gives clinicians
the option of using one single scan for the diagnosis, surgical planning, and treatment evaluation for
patients with lymphoedema.

MRL is consistently acknowledged for being quick, minimally invasive and avoiding ionizing
radiation [2,3,15,18,21,23,25,26] . GBCAs were considered safe, and no reactions or short-term complications in
patients with normal renal function were documented in any of the papers reviewed. In addition to being
safe, it has a reasonable specificity of absorption and transport within the lymphatic system .
[15]

The T2-weighted fat-suppressed MRI sequences provide information on other soft tissue changes, such as
adipose deposition and fibrosis [2,13,25] , and differentiate from other types of peripheral oedema [15,25] . MRIs
provide a wider field of view than lymphoscintigraphy, and by creating 3D images, superimposed vessels are
[34]
less likely to obscure detail . Since MRL does not require the cannulation of a single lymphatic vessel,
more vessels have the potential to uptake the contrast and be visualised. The detection rates of lymphatic
vessels and lymph nodes have been found superior in MRL compared to lymphoscintigraphy [13,24,25] . MRL
not only provides a real-time assessment of the transport function of the lymphatic system, but it can be
[15]
performed in a reasonable timeframe .

MRL can detect subclinical lymphoedema before it progresses to severe limb enlargement in the later stages,
allowing for conservative management to be commenced earlier and prevent progression to advanced
disease [2,36] . It is also valuable in a post-operative setting to monitor response to treatment and early
complications. Circumferential measurements of limbs at fixed positions are common practice for
[20]
lymphoedema surveillance. However, MRL is a more accurate form of surveillance . MRL has a range of
alternative uses, including tumour staging, evaluating retroperitoneal and abdominal lymphatic vessels,
[7,8]
visualising the thoracic duct, and it can be used to investigate post-operative lymphocele formation .
Bioimpedance spectroscopy (BIS) also demonstrated positive interim results to prevent breast cancer-
related lymphoedema compared to tape measurement . The combination of BIS and MRL has the
[41]
potential to help increase our understanding of the pathophysiology of lymphoedema and is a useful tool for
ongoing research.