We read with great interest the article entitled “Donor-Site Lymphatic Function after Microvascular Lymph Node Transfer” by Viitanen et al. Their work is revolutionary in that they attempted to evaluate objectively the donor groin site lymphatic vessel function after lymphatic transfer using lymphoscintigraphy.1 As they have pointed out, symptoms of lymphedema could develop following surgery or trauma, and therefore nobody can deny the possibility that lower limb lymphedema could develop as a result of treating upper limb lymphedema. If this is so, it is our duty to explain this fact to patients before they undergo surgery.
Viitanen et al. applied lymphoscintigraphy to 10 patients to evaluate the donor-site limbs. In their article, they reported that minor changes in lymphatic flow in the donor sites were revealed in six of 10 patients postoperatively but that none of the patients reported any symptoms in their lower extremities.
We already reported the same concept and named it a subclinical lymphedema using indocyanine green lymphography, not lymphoscintigraphy.2 We found that even asymptomatic limbs with lower extremity lymphedema could be detected by the dermal backflow pattern of indocyanine green lymphography. In our article, we showed that the lymphatic flow abnormality proceeds from a splash pattern to a stardust pattern and finally to a diffuse pattern.2–4 We concluded that the splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of lower extremity lymphedema patients. That is why we should follow patients cautiously once we encounter the splash pattern in postoperative limbs. Through our series, we found that lymphedema of upper limbs and that of lower limbs show the same dermal backflow pattern.4
The most important difference between indocyanine green lymphography and lymphoscintigraphy is sensitivity.5 We compared indocyanine green lymphography and lymphoscintigraphy for early detection of lymph flow dysfunction, and reported that the sensitivity of indocyanine green lymphography is 100 percent compared with 62 percent for lymphoscintigraphy. This is the strongest reason we should use indocyanine green over lymphoscintigraphy when discussing donor-site morbidity. Early detection of lymphedema could prevent further progression and therefore we are convinced that, for this purpose, indocyanine green lymphography is superior to lymphoscintigraphy.
In treating lymphedema, we believe it is important whether there is donor-site morbidity or not and thus we should not only follow patients for longer periods but also use safe, easy, sensitive, and inexpensive tests to detect the condition as early as possible in case there are no signs of lymphatic dysfunction. Thus, we would recommend using indocyanine green instead of lymphoscintigraphy for diagnosis of lymphedema. However, this article must be considered as one of the most important articles in the field of lymphedema because it is the first article to attempt to focus on undesirable results of a promising technique.
Shuchi Azuma, M.D.
Takumi Yamamoto, M.D.
Isao Koshima, M.D.
Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
The authors have no financial interest to declare in relation to the content of this article.
1. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg. 2012;130:1246–1253.
2. Yamamoto T, Matsuda N, Doi K, et al.. The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: The modified dermal backflow stage and concept of subclinical lymphedema. Plast Reconstr Surg. 2011;128:314e–321e.
3. Yamamoto T, Narushima M, Doi K, et al.. Characteristic indocyanine green lymphography findings in lower extremity lymphedema: The generation of a novel lymphedema severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;127:1979–1986.
4. Yamamoto T, Yamamoto N, Doi K, et al.. Indocyanine green-enhanced lymphography for upper extremity lymphedema: A novel severity staging system using dermal backflow patterns. Plast Reconstr Surg. 2011;128:941–947.
5. Mihara M, Hara H, Araki J, et al.. Indocyanine green (ICG) lymphography is superior to lymphoscintigraphy for diagnostic imaging of early lymphedema of the upper limbs. PLoS One 2012;7:e38182.
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