LAUSR

Dear Editor, Lymphaticovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and vascularized lymph vessel transfer (VLVT) are the most used microsurgical techniques for the treatment of lymphedema (Chen, McNurlen, Ding, & Bowen, 2019; Ciudad et al., 2017; Ciudad, Manrique, Bustos, Agko, et al., 2020; Ciudad, Manrique, Bustos, Vargas, et al., 2020; Koshima et al., 2016). These procedures aim to improve the lymphatic drainage of the affected limb. Donor sites described in literature for VLVT include the dorsum of the foot, the lateral thoracic area, and the abdominal-inguinal region (Chen et al., 2019; Koshima et al., 2016). Advantages of VLVT transfer include: safe procedure, minimally invasive surgery with small incisions, and elevation of the flap takes less than an hour. The disadvantages include: small risk of lymphedema in the donor foot (Koshima et al., 2016). Recently indocyanine green (ICG) lymphography has become a popular imaging technique used in the diagnosis and treatment of lymphedema (Ciudad, Manrique, Bustos, Agko, et al., 2020). The aim of this letter is to report the use of preoperative ICG lymphography for evaluation and mapping the lymphatic system from the donor site for planning of a lymph vessel flap harvest. Herein we describe the case of a 20-year-old woman diagnosed with postmastectomy right upper extremity lymphedema who underwent LVA 18 months ago. The patient reported satisfactory postoperative clinical outcome in the majority of the affected limb except at the level of the hand. Surgical options such as VLNT and VLVT were offered and explained in detail. She refused to receive VLNT due to the potential risk of complications and decided to undergo a VLVT based on the first dorsal metatarsal artery (first dorsal metatarsal artery-based VLVT). Preoperative ICG lymphography was performed at the level of both feet in order to locate and evaluate the lymphatic system as a potential donor site for VLVT (Figure 1a). Flap design was performed according to preoperative ICG findings (Figure 1b). Under general anesthesia, a skin incision was made at the level of the dorsum of the foot. The flap was harvested with the first dorsal metatarsal artery and one concomitant vein as the vascular pedicle. Subsequently, the flap was transferred to the dorsum of the hand and anastomosed to a branch of the common dorsal carpal network artery and superficial vein from the dorsum of the hand, respectively. Donor and recipient site were closed primarily. The patient was discharged on postoperative Day 1. At the 18-month follow-up, the patient showed reduction of volume and improvement in hand functionality (Figure 1c,d). No complications were observed in the donor site during the follow-up period.