We read with great interest the article entitled “Noncontrast Magnetic Resonance Lymphography for Evaluation of Lymph Node Transfer for Secondary Upper Limb Lymphedema” by Arrivé et al.1 Their work is a true innovation in that they established objective criteria for evaluation of the efficacy of lymph node transfer using noncontrast magnetic resonance lymphography. Although they were able to visualize dilated lymphatic vessels in some cases in their report, it is still a challenge to use these data for identification of dilated lymphatic vessels intraoperatively because the lymphatic vessels are extremely small compared with the size of the upper extremity; this may be comparable to finding a needle in a haystack.
Finding the lymphatic vessels with remaining function is crucial for successful lymphaticovenular anastomosis. For treatment of lower extremity lymphedema, Seki et al. reported a method for increasing the chances of finding a functional lymphatic vessel feasible for lymphaticovenular anastomosis.2 However, surgeons generally face technical difficulties when performing lymphaticovenular anastomosis on the upper extremity: when compared with the lymphatic vessels in the lower extremity, the lymphatic vessels in the upper extremity are smaller in diameter (usually <0.5 mm), even in lymphedematous patients.3 These difficulties have led surgeons to veer away from lymphaticovenular anastomosis to lymph node transfer.
As of now, the gold standard modality for detection of lymphatic vessels in the upper extremity is indocyanine green lymphography, which can be used for severity evaluation and preoperative detection.4 However, many lymphedematous patients present with a stardust or diffuse pattern, covering up the lymphatic vessels. In addition, the lymphatic vessels running in deeper layers cannot be visualized. An alternative modality is ultrasonography.5 Ultrasonography can visualize the lymphatic vessels even in regions with a stardust or diffuse pattern, or in deeper layers. However, it is an extremely examiner-dependent examination.
To address these issues hampering detection of satisfactory lymphatic vessels in the upper extremity, we propose an innovative hypothesis and a method deduced from this postulation. Although the lymphatic vessels are known to possess a self-pumping function by means of smooth muscles, the main collector lymphatic vessels can be presumed to be located in regions where continual pressures are applied to the lymphatic vessels in intervals from the underlying muscles. This corresponds to the location of the veins, which is affected by the surrounding muscles. From this supposition, in the setting of progressive lymphedema with obstruction of the lymphatic flow in the upper stream, we can deduce that there are higher chances of finding functional and sizable lymphatic vessels in the region physically affected most by the underling muscles.
Based on this hypothesis, we looked for regions with vigorous “pumping” from the underlying muscle in the upper extremity using ultrasonography while asking patients to flex and extend their fingers. (See Video, Supplemental Digital Content 1, which shows cross-sectional ultrasonography of the upper extremity preoperatively. In most patients, when asked to flex and extend their fingers, the greatest vertical movement of the underlying muscle layer was observed at the medial and lateral region of the forearm, above the superficial flexor muscles and the brachioradialis muscle, http://links.lww.com/PRS/D5.) As a result, in most patients, the greatest vertical movement (examined with cross-sectional ultrasonography) of the underlying muscle layer was observed at the medial and lateral region of the forearm, above the superficial flexor muscles and the brachioradialis muscle.
We have used this method for identification of lymphatic vessels in lymphaticovenular anastomosis of the upper extremity. Interestingly, in these regions with rigorous movement of the underlying muscles, functional lymphatic vessels with diameters larger than 0.5 mm could often be found, even in patients with a stardust or diffuse pattern in the forearm, or in cases where indocyanine green lymphography could not be performed because the patient was likely to show allergic reactions to indocyanine green. Our preliminary results have been very encouraging (Fig. 1).
This report was published with the consent and permission of the patients involved.
None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this communication.
Hidehiko Yoshimatsu, M.D.Department of Plastic and Reconstructive SurgeryCancer Institute Hospital of the Japanese Foundation forCancer Research
Takumi Yamamoto, M.D.Department of Plastic and Reconstructive SurgeryUniversity of TokyoGraduate School of Medicine
Kenta Tanakura, M.D.Department of Plastic and Reconstructive SurgeryCancer Institute Hospital of the Japanese Foundation forCancer Research
Yuma Fuse, M.D.Akitatsu Hayashi, M.D.Department of Plastic and Reconstructive SurgeryUniversity of TokyoGraduate School of MedicineTokyo, Japan
1. Arrivé L, Derhy S, Dlimi C, El Mouhadi S, Monnier-Cholley L, Becker C. Noncontrast magnetic resonance lymphography for evaluation of lymph node transfer for secondary upper limb lymphedema. Plast Reconstr Surg. 2017;140:806e811e.
2. Seki Y, Yamamoto T, Yoshimatsu H, et al. The superior-edge-of-the-knee incision method in lymphaticovenular anastomosis for lower extremity lymphedema. Plast Reconstr Surg. 2015;136:665e675e.
3. Yamamoto T, Narushima M, Yoshimatsu H, et al. Minimally invasive lymphatic supermicrosurgery (MILS): Indocyanine green lymphography-guided simultaneous multisite lymphaticovenular anastomoses via millimeter skin incisions. Ann Plast Surg. 2014;72:6770.
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;128:941947.
5. Hayashi A, Hayashi N, Yoshimatsu H, Yamamoto T. Effective and efficient lymphaticovenular anastomosis using preoperative ultrasound detection technique of lymphatic vessels in lower extremity lymphedema. J Surg Oncol. 2018;117:290298.