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Page 2 of 9 Shetty. Plast Aesthet Res 2022;9:47 https://dx.doi.org/10.20517/2347-9264.2022.41

MRL is an MR examination in which the peripheral lymphatic channels and subcutaneous soft tissues of an
[9]
extremity are evaluated in a multiparametric fashion . A multisequence protocol provides an anatomical
assessment of fluid and fat distribution, lymphatic contrast injection and subsequent imaging of lymphatic
drainage, and intravenous contrast injection and subsequent imaging to assess venous outflow,
comprehensively evaluating the extremity to guide treatment planning [5,10] . This manuscript will detail how
to start a peripheral MRL program using an organized, methodical team-based approach, which will be
divided into visioning, analysis, implementation, and reflection.

VISIONING PHASE
During this phase, the collaboration of key stakeholders is critical in crafting a vision . In this case, the
[11]
vision is to improve the care of lymphedema patients by offering targeted surgical therapy, guided in part by
the diagnostic imaging of MRL. Collaborating with a radiologist to champion this effort is imperative, as the
champion will identify colleagues within the radiology infrastructure whose shared efforts will be crucial in
the success of the venture, such as radiologists who will perform the web space lymphatic injection and
radiologists who will interpret the MRL exam (they may be the same individual or different), technical staff
to build and perform the MR protocol, and ancillary staff to schedule, protocol, and bill for these novel
exams . Having an answer to every possible question is less important at this stage than openly
[12]
communicating with the radiology department leadership about why this vision matters.

ANALYTICAL PHASE
During this phase, the radiology champion may consider conducting a SWOT (strengths, weaknesses,
opportunities and threats) analysis to determine current strengths and weaknesses and potential
[13]
opportunities and threats . In our case, strengths included a new state-of-the-art MR scanner with the
latest technologies, MR technologists willing, familiar, and capable of building new MR protocols in
collaboration with radiologists, a plastic surgery referral service strongly supportive of this initiative, and
information technology (IT) and billing support. Weaknesses included the complexity of establishing a new
service line, determining who would have the expertise, willingness, and availability to perform lymphatic
injections, and expertise in interpreting an unfamiliar exam. Opportunities include being able to offer and
market a unique new service line, growth of clinical revenue, and esprit de corps in collaborating to care for
these clinically challenging patients. Threats include loss of patients to competitors offering these clinical
services/imaging and loss of productivity in the lead-up to developing an efficient process for performing
and interpreting these exams.

At this stage, we identified the key stakeholders outlined in Figure 1. We recognized that our
musculoskeletal radiologists were ideally positioned to perform the web space lymphatic magnetic
resonance imaging (MRI) contrast injection both physically, in close proximity to the MR scanners, and
technically, as they are adept and comfortable in performing injections. A specific MR scanner was
designated for performing these exams at two different campuses because of the availability of specific MR
coils (a “runoff” or whole body coil to provide adequate anatomic coverage of the pelvic/lower extremity)
[14]
and a large field of view needed to image the extremities efficiently . An advanced MR technologist was
recruited to assist in building the MRI protocol on the scanner and to perform the initial examinations with
the supervision of the radiology champion. Our IT group was consulted early in the process to create the
codes that would be needed to order these exams in the health information management system (HIMS)
and modify the electronic form within the HIMS used by radiologists to protocol the exams. We also
worked closely with IT to eventually build display protocols in the radiology picture archival and
communication system (PACS) to display these exams for efficient viewing and interpretation. Scheduling
was also more complex than a standard MR exam because of the need for injection of the lymphatic