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Page 4 of 9 Shetty. Plast Aesthet Res 2022;9:47 https://dx.doi.org/10.20517/2347-9264.2022.41

IMPLEMENTATION PHASE
Our first clinical MRL exam took place approximately 5 months after the initiation of the project. As with
any new endeavor, expected and unexpected challenges were encountered. The radiologist performing the
webspace injections found that using a single 25-gauge syringe for injections was far simpler than multiple
30 gauge tuberculosis syringes. Reconstruction of the numerous imaging data sets on the scanner was
lengthier than anticipated, and the volume of images for the first exam numbered over 25,000, creating
difficulties in actually loading and reading the exam on PACS.

Iterative development of the clinical and imaging protocol has been an essential component of the success
of the MRL imaging program. As we accrued more experience, several changes were made to the imaging
protocol, including reducing the number of dynamic MRL acquisitions from every 5 min to every 10 min
over a 30-min span, reducing the overall number of images. The upper extremity protocol was modified to
include a large field of view image to allow at least a partial comparison of both upper extremities [Figure 2]
and the imaging plane was changed from sagittal to coronal to make interpretation more straightforward.
We developed a patient educational flyer [Figure 3] to prepare patients for what to expect during the exam
and began having patients administer topical lidocaine to the injection web spaces prior to the exam to
decrease discomfort. As we moved to a new PACS, a new display protocol was developed to make image
interpretation more efficient.

Our current state is performing approximately 7 to 8 MRL exams per month, roughly 60% of the upper
extremities and 40% of the lower extremities. The current MRL protocols are listed in Tables 1 and 2 for
reference, with sample images in Figure 4. After initially only being performed by a single MR technologist
at each site, other technologists now have the training and experience to perform diagnostic exams. A single
radiologist still interprets most MRL exams in our practice, but educational material has been developed for
other radiologists who have expressed interest to begin learning to interpret these exams.

REFLECTION
Establishing an MRL imaging program is not an impossible task but one that can be achieved with detailed
organization. Every radiology practice is structured differently and what worked for us may not be feasible
or advantageous for others. However, certain factors are important to keep in mind when setting up an
MRL imaging program.

The lymphatic injection component of the exam can prove to be a difficult logistical challenge. Maximizing
flexibility for the physicians performing the injections aids in creating a successful partnership. Rather than
setting up our exam to acquire images prior to contrast injection, which would require the injecting
radiologist to be available at short notice to perform the injection with the patient already on the scanner,
we decided to have the exam start only after the radiologist performed the injection, giving them greater
flexibility. Our entire group of musculoskeletal radiologists participate in performing the injections,
simplifying the scheduling of these exams.

Positioning of patients for the upper extremity exam can also be variable, depending on what the patient
can tolerate for a 45- to 60-min exam. Ideally, a patient would be able to keep their arm raised above their
head, but this is frequently not feasible and the arm is then imaged at the side, creating challenges with the
field of view and uniformity of image quality. Performing the exam on a newer large bore (70 cm diameter)
MR scanner with a larger field of view is helpful for optimizing image quality.