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Reply: Noncontrast Magnetic Resonance Lymphography for Evaluation of Lymph Node Transfer for Secondary Upper Limb Lymphedema

Arrivé, Lionel, M.D.; Becker, Corinne, M.D.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 603e-604e
doi: 10.1097/PRS.0000000000004749

Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne Université

Department of Thoracic Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France

Correspondence to Dr. Arrivé, Department of Radiology, Saint-Antoine Hospital, 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France,

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We appreciate the valuable comments and perspective of Yoshimatsu et al.1 regarding our recent article2 describing the results of axillary lymph node transplantation with noncontrast magnetic resonance lymphography in 15 patients with secondary upper limb lymphedema. In this article, we demonstrated that distal dilated lymphatic vessels in the arm were observed in four patients (Fig. 1).2

Fig. 1.

Fig. 1.

In their letter, Yoshimatsu et al. indicated that identification of dilated lymphatic vessels before lymphaticovenular anastomosis remains a challenge despite visualization of such dilated vessels with magnetic resonance lymphography. They described a new method for identification of lymphatic vessels using ultrasonography after vigorous pumping from the underlying muscles in the upper extremity.1

We definitely agree with the comments by Yoshimatsu et al. As a matter of fact, the standard of reference for detection of the lymphatic channels in the upper extremity is indocyanine green lymphography.3 However, limitations of indocyanine green lymphography include a relatively small field of view and markedly limited penetration depth.4 Therefore, indocyanine green lymphography cannot be used to analyze deep lymphatic vessels.4 Ultrasonography is uncommonly performed to demonstrate dilated lymphatic vessels in patients with lymphedema.5 In their letter, Yoshimatsu et al. propose an innovative method for improving detection of lymphatic vessels with ultrasonography by means of a pumping movement of the underlying muscles. Nevertheless, the ideal technique for identification of dilated lymphatic vessels remains elusive. We assume that a multimodality approach could be used—including magnetic resonance lymphography, indocyanine green lymphography, and ultrasonography—if the preliminary results of Yoshimatsu et al. are confirmed.1 These authors should be commended for their innovative technique.

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

Lionel Arrivé, M.D.Department of RadiologySaint-Antoine HospitalAssistance Publique-Hôpitaux de ParisSorbonne Université

Corinne Becker, M.D.Department of Thoracic SurgeryHôpital Européen Georges PompidouAssistance Publique-Hôpitaux de ParisParis, France

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1. Yoshimatsu H, Yamamoto T, Tanakura K, Fuse Y, Hayashi A. Noncontrast magnetic resonance lymphography for evaluation of lymph node transfer for secondary upper limb lymphedema [Letter]. Plast Reconstr Surg. 2018;142:601e603e.
2. 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.
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, Yoshimatsu H, Narushima M, Yamamoto N, Hayashi A, Koshima I. Indocyanine green lymphography findings in primary leg lymphedema. Eur J Vasc Endovasc Surg. 2015;49:95102.
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.
Copyright © 2018 by the American Society of Plastic Surgeons