Microsurgical Lymphaticovenous Implantation Targeting Dermal Lymphatic Backflow Using Indocyanine Green Fluorescence Lymphography in the Treatment of Postmastectomy Lymphedema

Background: Microsurgical lymphaticovenous implantation in lymphedema is done to create a lymphaticovenous shunt by an implantation of collecting lymphatics into the small vein, as reported previously. The authors have recently introduced ultrasonograpy and indocyanine green fluorescence lymphography into this procedure. Methods: Nine cases of postmastectomy lymphedema had received preoperative venous marking using ultrasonography and lymphatic mapping using indocyanine green fluorescence lymphography. The concept of modification is to pick up the most effective point for microsurgical lymphaticovenous implantation that involves both subcutaneous veins and the dermal backflow of excess lymphatics. Objective improvement was analyzed by the percent reduction of edema circumference at two points of the affected forearm. Results: Preoperative lymphography showed a spotty image for dermal backflow in all nine extremities, a linear image on the dorsal hand in six extremities, and a linear image on the forearm in three extremities. With an average follow-up of 17 months, three patients had excellent results with the reduction of edema circumference more than 50 percent for both the distal and proximal sites of the treated forearm. Four patients had good results with the reduction of edema circumference more than 50 percent at the distal or proximal sites, two patients had fair results, and no patients had poor results. The average number of modified microsurgical lymphaticovenous implantations was 3.7 per case. Conclusion: Modified microsurgical lymphaticovenous implantation is expected to provide favorable results with aminimum number of these modified implantations, even though no linear lymph channel was detected by preoperative indocyanine green fluorescence lymphography. (Plast. Reconstr. Surg. 127: 1804, 2011.)