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Page 10 of 12 Lasso. Plast Aesthet Res 2020;7:30 I http://dx.doi.org/10.20517/2347-9264.2019.75

In this study, we evaluated the changes in lymphatic drainage one year after LVA and corroborated the
effectiveness of surgical treatment. Our study population included a small group of randomly selected
patients that were included in a prospective study. After analysis of lympho-SPECT-CT findings, we
reported that in a majority of patients, regardless of the degree of lymphedema, there was evidence
corresponding to new lymphatic circulation in images of the limbs (upper and lower limbs). We believe
that LVA was not only useful in the reestablishment of lymphatic drainage through the venous by-passes,
but also in developing collateral circulation (especially in two cases with extraanatomical landmarks). This
[19]
could be explained in relation to the activation of new routes of drainage . Cases with new lymph nodes
[20]
may indicate that drainage is greater, as has been demonstrated in experimental models . Interestingly,
ICG findings are in concordance with these positive landmarks but we could not compare qualitative
variables with quantitative ones to perform a better statistical analysis. In seven cases, we clearly observed
that the linear pattern [21,22] obtained after LVA was accompanied by more remarkable findings on lympho-
SPECT-CT.

On the other hand, we were able to evaluate the correlation between clinical parameters such as the
volume of the limbs and findings on lympho-SPECT. In this case, we observed an inverse correlation
coefficient with statistical significance, indicating that the reduction of limb volume that is observed
after LVA is associated with a significant increase in the number of landmarks that support improvement
and reestablishment of lymphatic drainage. There are many factors influencing the final result. This is
a heterogeneous group of patients, with different ages and time of evolution of lymphedema. Our work
includes both upper and lower limb lymphedema of different ISL stages, which make comparisons difficult.
It has also been demonstrated that LVA studies have a poor quality of evidence and high risk of bias, and
[23]
therefore, it is difficult to draw reliable conclusions on the clinical effectiveness of LVA .
Nevertheless, LVA seems to be safe for the treatment of primary and secondary lymphedema. If a reduction
of volume can be demonstrated after LVA, we may think that lymphatic drainage has improved. In order to
prove this, nuclear medicine testing would be an objective method to do so. If we are able to demonstrate
such improvement by means of functional and anatomical landmarks (the development of new lymph
nodes or the establishment of collateral circulation) that were not visible before surgery, we would then
be in a position to confirm that surgery has been effective as it has been demonstrated that 99mTc-
phytate lymphoscintigraphy with SPECT-CT can provide both functional and morphological information
simultaneously in patients with upper-limb lymphedema . Using this modality, SPECT-CT may accurately
[24]
reflect lymphodynamic conditions of the limbs after LVA. Furthermore, the surgical therapeutic efficacy
could be estimated quantitatively by comparing pre- and postoperative findings.

In conclusion, our results have showed a postoperative decrease in volume of limbs with lymphedema
that correlated inversely with lympho-SPECT/CT findings. Lympho-SPECT/CT provided additional
information related to the accurate identification and anatomical location of lymphatic structures that
were not observed before reconstructive surgery. It should be a complementary test to conventional
lymphoscintigraphy.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Data supporting these findings can be found. Data can be deposited into the data repositories of the
hospital, which can be accessed but not sent externally except for legal reasons.