Plastic & Reconstructive Surgery:
Use of Indocyanine Green Fluorescent Lymphography for Evaluating Dynamic Lymphatic Status
Suami, Hiroo M.D., Ph.D.; Chang, David W. M.D.; Yamada, Kiyoshi M.D.; Kimata, Yoshihiro M.D.
Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas (Suami, Chang)
Department of Plastic and Reconstructive Surgery, Okayama University, Okayama, Japan (Yamada, Kimata)
Correspondence to Dr. Suami, Department of Plastic Surgery, Unit 443, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030-4009, firstname.lastname@example.org
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Visualization of the lymphatic system is a challenging problem. Recently, an indocyanine green fluorescent lymphography system was developed for visualizing the lymphatic vessels.1–3 Indocyanine green is a water-soluble compound, and it has been widely used for assessing cardiac output, hepatic function, and ophthalmic angiography. Indocyanine green emits energy in the near-infrared region between 750 and 810 nm when it is bound to protein in the tissue. This feature is advantageous for investigating deep tissue structures.
We used an indocyanine green fluorescent lymphangiography system (Photodynamic Eye; Hamamatsu Photonics K.K., Hamamatsu, Japan) composed of a camera unit, near-infrared–emitting diodes, and a controller unit that operates the camera. The charge-coupled device camera has a fixed focus ranging from 15 to 25 cm, which allows investigation of a 10 × 10-cm field with one image. The system can detect anatomical structures by detecting near-infrared radiation in the tissue at a depth of approximately 10 mm from the surface.
The lymphatic anatomy in the upper extremity was investigated using indocyanine green fluorescent lymphography in three healthy volunteers without any medical history of vascular disease or lymphedema. Indocyanine green (0.01 to 0.02 ml) was injected into each finger web intradermally. After a few minutes, fluorescent images of lymphatic vessels emerged at the dorsal hand and ran longitudinally toward the proximal arm (Fig. 1). (See Video, Supplemental Digital Content 1, which demonstrates indocyanine green fluorescent lymphography in a healthy limb, http://links.lww.com/PRS/A297.) They ascended in the posterior forearm and then gradually changed direction toward the medial side of the upper arm en route to the axilla. The flow was facilitated by spontaneous muscle movement and squeezing the vessel from the outside.
We used indocyanine green fluorescent lymphography in three patients with breast cancer–related lymphedema under general anesthesia before a lymphaticovenular shunt operation. Indocyanine green was injected intradermally into the finger webs and at three locations at the volar side of the wrist. Soon after the injections, fluorescent stains were identified proximal to the injection sites. The lymphatic vessels could be identified at the dorsal hand, but a patchy reticular honeycomb-like structure could be seen in the forearm instead of the linear structure seen in the healthy volunteers without lymphedema (Fig. 2). (See Video, Supplemental Digital Content 2, which demonstrates indocyanine green fluorescent lymphography in a lymphedematous limb, http://links.lww.com/PRS/A298.) In two cases, one or two collecting lymphatic vessels could be identified at the medial elbow region. Skin incisions (approximately 2 to 3 cm) were made at these identified sites, and prominent and patent lymphatic vessels were found. Surgical findings and image data were concurrent with high accuracy.
We demonstrated the differences in the anatomy of the lymphatic system between healthy upper limbs and lymphedematous limbs. We observed the reticular structures only in the lymphedematous limbs. These findings are similar to the “dermal backflow” sign observed in lymphangiography and lymphoscintigraphy.4,5
Using this indocyanine green system, an incision can be made precisely over the collecting lymphatic vessels. This allows for the prompt identification of the functional lymphatic vessels and has the potential to significantly improve the outcomes of lymphovenous shunt operations.
Hiroo Suami, M.D., Ph.D.
David W. Chang, M.D.
Department of Plastic Surgery
University of Texas M. D. Anderson Cancer Center
Kiyoshi Yamada, M.D.
Yoshihiro Kimata, M.D.
Department of Plastic and Reconstructive Surgery
The authors have no financial interest to declare in relation to the content of this article.
1. Kitai T, Inomoto T, Miwa M, Shikayama T. Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer. Breast Cancer
2. Unno N, Inuzuka K, Suzuki M, et al. Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema. J Vasc Surg.
3. Ogata F, Narushima M, Mihara M, Azuma R, Morimoto Y, Koshima I. Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema. Ann Plast Surg.
4. Feldman MG, Kohan P, Edelman S, Jacobson JH II. Lymphangiographic studies in obstructive lymphedema of the upper extremity. Surgery
5. Sty JR, Boedecker RA, Scanlon GT, Babbitt DP. Radionuclide “dermal backflow” in lymphatic obstruction. J Nucl Med.
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David H. Song, M.D., M.B.A. is the President-elect of the American Society of Plastic Surgeons (ASPS). He is a consultant with BioMet, Emmi Solutions, LLC, a consortium-member providing senior debt for Brava, and consultant with and investor in HealthEngine.com. He receives author royalties from Elsevier. Scot Glasberg, M.D. is the President of the American Society of Plastic Surgeons (ASPS). He is a consultant with LifeCell Corp and Mentor Corp and an investor with Strathspey Crown. The authors have no sources of funding to report related to the writing or submission of this discussion.
The location and affiliation information should read as follows: Arlington Heights, Ill. From the American Society of Plastic Surgeons/Plastic Surgery Foundation.
David H. Song, M.D., M.B.A., 444 E. Algonquin Rd. Arlington Heights, IL 60005, email@example.com
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