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Reply: A Prospective Analysis of 100 Consecutive Lymphovenous Bypass Cases for Treatment of Extremity Lymphedema

Chang, David W. M.D.; Suami, Hiroo M.D., Ph.D.; Skoracki, Roman M.D.

Plastic and Reconstructive Surgery: June 2014 - Volume 133 - Issue 6 - p 888e–889e
doi: 10.1097/PRS.0000000000000209

Section of Plastic and Reconstructive Surgery, Department of Surgery, Medicine and Biological SciencesThe University of Chicago, Chicago, Ill.

Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas

Correspondence to Dr. Chang, Section of Plastic and Reconstructive Surgery, Department of Surgery, Medicine and Biological Sciences The University of Chicago, 5841 South Maryland Avenue, Room J641, MC 6035, Chicago, Ill. 60637

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We would like to thank Drs. Yamamoto and Koshima for their insightful comments. We agree that what is critically important is to precisely identify functioning lymphatic vessels for lymphovenous bypass. We are aware that the lymphatic vessels do run along the great saphenous and cephalic vein; these are called the median or medial bundle.1 However, these lymphatic vessels are not always detected during indocyanine green lymphography, meaning that they are not always functional in certain lymphedema patients. We speculate that in these patients the associated lymph nodes or the proximal portion of the medial lymphatic bundle were excised or damaged during the axillary or inguinal dissection. Thus, just relying on our knowledge of lymphatic anatomy alone is not sufficient for identifying optimal lymphatic vessels for bypass.

We have found that the best way to identify functioning lymphatic vessels for lymphovenous bypass is to perform indocyanine green fluorescence lymphography and mapping of the functioning lymphatic vessels just before surgery. As soon as the indocyanine green is injected, fluorescent images of the functioning lymphatic vessels can be visualized using a Hamamatsu Photodynamic Eye (Hamamatsu Photonics, Hamamatsu, Japan), and the mapping is performed on the skin surface immediately. As time passes, even after just 10 to 15 minutes, indocyanine green dye refluxes into the superficial and subdermal lymphatics of the limb, creating the various patterns of dermal backflow, as described by Drs. Yamamoto and Koshima. Once this occurs, the linear patterns of functioning lymphatic vessels often are no longer visible, as they are overshadowed by dermal backflow.

We agree with Drs. Yamamoto and Koshima that the type of dermal backflow is important for staging, but we have found in our experience that the quality and the quantity of functioning lymphatic vessels identified by indocyanine green fluorescence lymphography just before surgery not only facilitate the operation but are among the key factors in determining the outcome following lymphovenous bypass.

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The authors have no financial interest to declare in relation to the content of this communication.

David W. Chang, M.D.

Section of Plastic and Reconstructive Surgery

Department of Surgery

Medicine and Biological Sciences

The University of Chicago

Chicago, Ill.

Hiroo Suami, M.D., Ph.D.

Roman Skoracki, M.D.

Department of Plastic Surgery

The University of Texas M. D. Anderson Cancer Center

Houston, Texas

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1. Kubik S, Kretz O. Anatomy of the lymphatic system. Földi’s Textbook of Lymphology. 2006 Munich Elsevier GmbH:1–149
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