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Page 4 of 9 Minasian et al. Plast Aesthet Res 2022;9:18 https://dx.doi.org/10.20517/2347-9264.2021.128

Burns
Burns are another significant etiology of PTL [8,23] . Lymphatic channels exist in a complex network abundant
[8]
in the reticular dermis and underlying fat . This superficial location makes lymphatics particularly
susceptible to any trauma to the skin, including deep burn injuries. A 2004 study by Hettrick et al.
[8]
included a review of the literature, along with both retrospective and prospective studies regarding
lymphedema following burns. This study found a 1% prevalence and noted that fascial excision and
circumferential extremity involvement as risk factors for the development of lymphedema after burn injury.
It further noted that although burn scar was difficult to distinguish from the fibrosclerotic and color
changes associated with lymphedema, other typical clinical diagnostic signs of lymphedema were found to
be useful in the burn population.

Abdominal lymphedema
Abdominal lymphedema after trauma is a rare but reported complication after both penetrating and blunt
trauma, and manifests as chylous ascites or chyloretroperitoneum . These injuries are typically not isolated
[24]
since the forces required to disrupt the cisterna chyli or the thoracic duct in the chest, abdomen, or neck will
typically also injure other structures such as the liver, duodenum, kidney, and pancreas. Lymphangiography
[24]
is the imaging modality of choice . One patient with penetrating zone II neck injury developed transient
interruption of lymphatic flow and chyloretroperitoneum after ligation of the thoracic duct at the level of
drainage into the internal jugular vein. This self-resolved five days later once collateral lymphatic flow was
[25]
compensated . Of note, aside from initial stabilization maneuvers such as ligation of the injured thoracic
duct, all reported cases of abdominal lymphedema were treated conservatively with paracentesis, total
parenteral nutrition, medications (octreotide, somatostatin), and a low-fat diet with medium-chain
triglyceride supplementation.

Critical lymphatic areas
Critical lymphatic areas have been identified in the upper and lower extremities. In these regions, the
increased density of lymphatic vessels creates susceptibility to lymphatic disturbances in the event of
[4]
trauma . These critical lymphatic areas include the anteromedial leg, medial aspect of the arm and thigh,
and medial aspect of the elbow and knee. Several case reports support this in their description of
lymphedema following high energy, but very focal trauma.

Three case reports discuss focal injuries to the anteromedial leg, which resulted in lymphocele,
lymphorrhea, or intractable ulcers [17-19] . Two case reports involve PTL secondary to isolated penile trauma.
In one case, secondary to paintball injury, severe penoscrotal lymphedema was diagnosed by magnetic
[26]
resonance and required several debulking and resurfacing procedures of the penis . More recently, a case
of chronic post-traumatic penile lymphedema was successfully treated with lymphovenous anastomosis .
[27]
Another report documents isolated blunt trauma to a patient’s medial leg region due to striking the steering
wheel in an accident. This resulted in ipsilateral lymphedema diagnosed via indocyanine green (ICG)
lymphography . Finally, one case report regarding a susceptible upper extremity region involved a patient
[28]
with repeated self-injury to the medial arm. Although incised wounds rarely cause peripheral lymphedema,
disruption of multiple collecting lymphatic vessels with repeated injury in a lymphatically dense region was
[29]
enough to cause lymphedema of the limb, diagnosed by lymphoscintigraphy .
DIAGNOSTIC AND TREATMENT APPROACH
Diagnosis of PTL
Diagnosis of PTL is possible with any modality normally used to diagnose lymphedema, including MR
lymphangiography, lymphoscintigraphy, and ICG. Indocyanine green, however, has several significant
advantages in PTL. Unno originally described the method in 2007 as an alternative to lymphoscintigraphy,