Search Results (58)

Background: Patients who undergo pelvic lymphadenectomy for gynecologic or genitourinary cancers have an increased risk of developing lower extremity lymphedema. Although total lymphadenectomy is performed, bilateral lower extremity lymphedema is rare. A state-of-the-art radiologic technique, single-photon emission computed tomography (SPECT) with radioisotope injection, was used to establish lymph flow physiology and identify retrograde lymphatic flow in patients with lower extremity lymphedema after lymphadenectomy. Methods: Data from patients who underwent treatment for lower extremity lymphedema were collected from January 2017 to December 2018. These patients had gynecological or genitourinary cancers and had undergone pelvic lymphadenectomy. Among them, 10 were evaluated for reverse lymph flow using SPECT. The radioisotope was injected solely into the subdermal area of the healthy foot, not the affected foot, in contrast to other studies. Four hours later, SPECT images were obtained and analyzed. The radiologic results were correlated with clinical observations. Results: Most patients had undergone surgery for gynecological cancers. The mean disease duration was 9.4 ± 8.1 years. Retention in the pelvis and hip was confirmed in seven out of ten patients; six patients showed reverse lymphatic flow in the affected limb. Conclusions: SPECT-CT imaging after tracer injection into the unaffected limb revealed retrograde lymphatic flow toward the clinically affected side in a substantial proportion of patients with unilateral lower-extremity lymphedema. Full article

Background: Lipedema is a progressive adipofascial disorder marked by painful nodular fat deposition that is often mistaken for obesity. While tumescent liposuction reduces limb volume with relative lymphatic safety, persistent large, painful lobules frequently remain, and excisional strategies risk iatrogenic lymphatic injury. We evaluated the application of intraoperative indocyanine green (ICG) lymphography to identify and preserve lymphatic channels during debulking surgery for symptomatic lipedema. Methods: We conducted a single-center case series (University of Pittsburgh Medical Center, July 2023–December 2024) of adults with lipedema refractory to conservative therapy who underwent a selective dermato-lipectomy (lobule/skin excision) with or without tumescent liposuction. Patients with clinical lymphedema or dermal backflow in ICG were excluded. Near-infrared ICG (SPY-PHI) was used for pre-incision mapping and real-time intraoperative guidance; lymphatic trajectories were marked and spared during lobule excision. Primary measures included dermal backflow patterns and lymph node transit time; secondary outcomes were complications and symptom burden (Lymphedema Life Impact Scale, LLIS) through ≥24 months. Results: Eight patients (five female/three male; mean age 49.5 ± 14.4 years; median BMI 52.65 kg/m²) underwent ICG-guided surgery. Preoperatively, linear lymphatic patterns were visualized up to the knee in all patients, but dermal backflow patterns could not be visualized in 83% from the level of the knee to the groin. Still, 67% demonstrated inguinal nodal uptake (mean transit 24 min), suggesting preserved lymphatic transport. All cases achieved intraoperative confirmation of intact lymphatic flow after debulking. The mean liposuction aspirate was 925 ± 250 mL per lower extremity; the mean excision mass was 2209 ± 757 g per lower extremity. Complications included two superficial cellulitis events (25%) and one wound dehiscence (12.5%); no hematomas or skin necrosis occurred. No patient developed clinical or imaging evidence of iatrogenic lymphedema during follow-up. Conclusions: Intraoperative ICG lymphography is a practical adjunct for lymphatic-sparing debulking of symptomatic lipedema, enabling real-time identification and preservation of superficial collectors while addressing focal lobules. This hybrid approach—targeted tumescent liposuction followed by ICG-guided superficial dermato-lipectomy—was associated with meaningful symptom improvement and a low morbidity in this early series. Full article

The lymphatic system is essential for maintaining the body’s fluid balance, lipid absorption, and immune regulation. The dysfunction of the lymphatic system is associated with a wide spectrum of disorders. These disorders include primary and secondary lymphedema, congenital malformations, and lymphatic neoplasms. In cancer patients, lymphatic remodeling is essential, which facilitates tumor progression and metastasis, while tertiary lymphoid structures (TLSs) develop during chronic inflammation and may be involved in anti-tumor immunity. This review highlights the immunological basis of lymphatic disorders, with a particular focus on cellular and molecular biomarkers that define disease states. The recent advances in molecular imaging techniques, such as ultrasonography (US), computed tomography (CT), and magnetic resonance lymphography (MRL), have improved and identified the diagnosis and therapeutic targets for lymphedema. Moreover, nanobiotechnology and nano-delivery tools have further enhanced the visibility of cancer cells by imaging. Artificial Intelligence (AI) in lymphatic systems have offered a new spectrum for disease prediction using forms of AI such as natural language processing (NLP), machine learning (ML), robotics-assisted approaches, fussy model (FM), and natural language processing (NLP)-based algorithms. Collectively, these advanced tools have improved diagnostic approaches and reveal exciting opportunities for future research and new therapeutic developments in patient care. Full article

Introduction: Axillary reverse mapping (ARM) aims to reduce the risk of breast cancer-related lymphedema (BCRL) by preserving and limiting dissection of arm-draining lymphatics. The ideal type of dye and the location of injection, which maximize the sparing of lymphatics and improve outcomes of immediate lymphatic reconstruction (ILR), remain under-studied. The current literature reports inconsistent visualization of lymphatics using blue dye alone, whereas indocyanine green (ICG) near-infrared (NIR) lymphography has shown improved rates. However, optimized dual-dye workflows integrating breast–plastics co-surgery are lacking. Methods: A retrospective review of patients who underwent ILR following ALND for breast cancer between June 2021 and June 2023 was conducted. Patients who underwent ARM using our dual-dye technique were included, utilizing intradermal injections of indocyanine green (ICG) into the wrist and isosulfan blue (ISB) into the upper arm. Axillary reverse mapping channels were categorized by the type of dye used to visualize. Dye injection site, number of lymphatic channels visualized, channel diameter (mm), time-to-first channel, coordinates relative to fixed landmarks, ILR configuration, and pathologic findings were reviewed. Mann–Whitney U tests were used to compare channel visualization rates between types of dye. Results: Of 26 patients, 21 underwent dual-dye mapping and were included. A total of 115 ARM channels were identified: 99 (86%) via ICG and 29 (25%) via ISB. A total of 64 lymphaticovenous anastomoses were performed (mean: 2.46 per patient). Both dyes were identified in the axilla in only 11.7% of patients. At the end of the study, the lymphedema rate was 12%. Conclusions: We developed a reproducible dual-dye ARM technique for ALND with planned ILR, reducing lymphedema risk while maintaining oncologic safety. Dual-dye mapping reveals that proximal and distal lymphatics exhibit both overlapping and divergent drainage to axillary nodes. ICG’s higher axillary detection rate may reflect true anatomical differences or dye properties. These findings support the need for individualized lymphatic mapping during breast cancer surgery to guide preservation techniques and reduce the risk of BCRL. Full article

Post-traumatic lymphedema (PTL) is a chronic and often under-recognized sequela of soft tissue trauma, leading to persistent swelling, functional impairment, and increased risk of infection. While lymphedema is traditionally associated with oncologic interventions, growing evidence highlights the significant burden of PTL in trauma patients. This review provides a comprehensive analysis of the current understanding of PTL, including epidemiology, risk factors, pathophysiology, diagnostic modalities, and treatment strategies. PTL often occurs after high-impact musculoskeletal injuries (such as open fractures with significant soft tissue loss) or burns (especially if deep or circumferential). This risk is increased if injury occurs at critical areas of increased lymphatic density (such as anteromedial leg, medial knee, medial thigh, medial elbow, or medial arm). Advances in imaging techniques, including indocyanine green lymphography and magnetic resonance lymphangiography, have improved early detection and classification of PTL. Management approaches range from conservative therapies, such as complete decongestive therapy (CDT), to surgical interventions, including lymphaticovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and vascularized lymph vessel transfer (VLVT)/lymph-interpositional-flap transfer (LIFT). We report on our experience with two patients. At our center, we diagnose and stage PTL with ICG lymphography and trial CDT for 6 months. If there is no significant improvement, we recommend LVA. If there is insufficient improvement after 12 months, we recommend LIFT/repeat LVA/VLNT. We also treat open fractures with significant soft tissue defects with LIFT, as prophylaxis against PTL. PTL remains an underdiagnosed condition, necessitating increased awareness and intervention to prevent long-term disability. Full article

Indocyanine green (ICG) is a fluorescent agent which is characterized by a wide range of applications in the proper visualization of the operating field, differentiation of vital structures, and localization of lesions to be excised. An investigation and overview of novel approaches of indocyanine green in modern gynecological oncology was conducted, including ovarian cancer surgery with its compartmental approach and compartmental surgery in endometrial cancer. Ureteral visualization and perfusion, lymphography, lymph node transfers, or the localization of anastomotic leakage in bowel surgery are examples of applications aimed at reducing the risk of surgical complications and improving the patients’ quality of life. The general use of indocyanine green in lymph node detection, subcategorized and analyzed, is constantly improved and reviewed. A therapeutic approach with macromolecules is being tested in preclinical models. Early results could suggest the future application of indocyanine green not only in broad-sense imaging but also as a cytotoxic agent conjugated with macromolecules. Further studies on the application of indocyanine green in laparoscopy, open surgery, and finally as a curative cytotoxic agent are needed. Full article

Postoperative edema is a nearly universal consequence of aesthetic surgery, yet its clinical implications and potential progression to lymphedema remain underexplored. This review examines the prevalence, pathophysiology, diagnostic criteria, and management strategies for edema and lymphedema following aesthetic procedures. A comprehensive search of PubMed, Embase, and Cochrane databases identified studies involving adult patients undergoing aesthetic surgeries with documented postoperative edema or lymphedema. The review found that while edema is expected postoperatively and is generally self-limiting, persistent or disproportionate swelling may indicate early lymphedema. Risk factors include extensive liposuction, body contouring, and procedures involving lymphatic disruption. Despite its significance, lymphedema remains underdiagnosed due to a lack of standardized diagnostic criteria and low clinical suspicion. Emerging imaging modalities, such as indocyanine green lymphography, enhance early detection, while conservative treatments, such as manual lymphatic drainage, compression, and physical therapy, remain first-line interventions. Increased awareness among surgeons and incorporation of lymphatic-preserving techniques are vital to reducing morbidity. This review underscores the importance of distinguishing transient edema from chronic lymphedema and calls for further research to establish evidence-based guidelines for diagnosis, prevention, and management of postoperative lymphedema in aesthetic surgery. Full article

Objectives: This research aims to examine the impact of intracystic hemorrhage (ICH) on therapeutic outcomes in children with macro or mixed cystic lymphatic malformation (cLM). Methods: This retrospective study included macro/mixed cLM cases with or without ICH who underwent treatment between January 2019 and June 2024. All patients were diagnosed using preoperative imaging findings and intraoperative indocyanine green (ICG) lymphography. The baseline data of enrolled cases were retrospectively collected. The clinical characteristics were documented, including gender, age, histological typing, location, maximum diameter, and intracystic condition. Patients with or without ICH were divided into two groups. The dependent variables for predicting an excellent outcome were analyzed using multivariable logistic regression models after adjusting for potential factors using a univariable regression model. Postoperative variables, including duration of negative drainage, local infection, scar hyperplasia, and follow-up, were compared between the two groups. Results: A total of 83 cLM patients were included (ICH group: n = 36 and without ICH group: n = 47). A complete absence of afferent lymphatic vessels was demonstrated using intraoperative ICG lymphography, suggesting the isolated nature of ICH cases. ICH (p = 031; OR, 2.560; 95% CI, 1.089–6.020) was identified as the main predictor, and younger patients (p = 035; OR, 0.415; 95% CI, 0.183–0.940) had a lower potential for excellent outcomes. For the postoperative variables, the ICH group exhibited a shorter duration of negative drainage than the without ICH group (p < 0.001), while no significant differences were found regarding local infection (p = 0.693) and scar hypertrophy (p = 0.648). Conclusions: Although characterized by aggressive progression and compressive symptoms, ICH emerges as an independent favorable prognostic predictor in macro/mixed cLM management, potentially attributable to its isolated nature. Full article

Classification of diseases is of great importance for early diagnosis and effective treatment processes. However, etiological factors of some common diseases complicate the classification process. Therefore, classification of health datasets by processing them with artificial neural networks can play an important role in the diagnosis and follow-up of diseases. In this study, disease classification performance was examined by using Extreme Learning Machine (ELM), one of the machine learning methods, and an opposition-based WSO algorithm with a random opposite-based learning strategy is proposed. Common health datasets: Breast, Bupa, Dermatology, Diabetes, Hepatitis, Lymphography, Parkinsons, SAheart, SPECTF, Vertebral, and WDBC are used in the experimental studies. Performance evaluation was made by accuracy, precision, sensitivity, specificity, and F1 score metrics. The proposed IWSO-based ELM model has demonstrated better classification success compared to the ALO, DA, PSO, GWO, WSO, OWSO metaheuristics, and LightGBM, XGBoost, SVM, Neural Network (MLP), CNN machine and deep learning methods. In the Wilcoxon test, it was determined that IWSO was p < 0.05 when compared to other algorithms. In the Friedman test, it was determined that IWSO was first in the ranking of success compared to other algorithms. The results reveal that the IWSO approach developed with ELM is an effective method for the accurate diagnosis of common diseases. Full article

Background and Clinical Significance: Breast cancer-related lymphedema (BCRL) is a chronic condition affecting up to 20% of breast cancer survivors. Manual lymphatic drainage (MLD) has traditionally included techniques to redirect lymph flow toward alternative pathways when axillary drainage is impaired. However, emerging imaging techniques suggest that most lymph continues to drain toward the ipsilateral axilla, and this has led to the widespread uptake of treatment protocols that exclude traditional redirecting movements, even in cases where personalized imaging is unavailable. Case Presentation: This case report describes a woman with BCRL affecting the right arm and hand who underwent 3 years of conservative lymphedema therapy, including MLD and self-massage techniques that incorporated traditional redirection strategies. Pre-operative indocyanine green (ICG) lymphography, performed after prolonged conservative treatment, confirmed the presence of an open alternative drainage pathway bypassing the axilla and demonstrated dermal flow along the redirected pathways towards a previously described “radial” pathway. These findings suggest that targeted manual therapy may have reinforced or optimized this compensatory route. Conclusions: This case highlights the potential risk of relying on a single form of assessment and generalized cohort imaging studies to guide individualized MLD protocols. In the absence of personal imaging, prematurely abandoning traditional redirection techniques may limit opportunities to establish functional alternative pathways, particularly in early edema in patients who have this anatomical variation. ICG lymphography provides valuable insight into compensatory lymphatic drainage. However, until imaging protocols are standardized and individual imaging is widely accessible, retaining traditional MLD techniques for newly diagnosed BCRL may be crucial for optimizing treatment outcomes. Future research should explore the long-term impact of manual therapy on alternative pathway development and function. Full article

Objectives: To assess the efficacy of magnetic resonance (MR) lymphography with gadobutrol contrast for sentinel lymph node (SLN) mapping in early-stage oral squamous cell carcinoma (OSCC). Methods: This pilot study compared the identification of SLNs by MR lymphography using a gadolinium-based contrast agent (gadobutrol) to conventional [^99mTc]Tc-nanocolloid lymphoscintigraphy (including single-photon emission computed tomography/computed tomography (SPECT/CT)) in 10 early-stage OSCC patients undergoing SLN biopsy. The patients initially underwent conventional lymphoscintigraphy following the peritumoral administration of indocyanine green [^99mTc]Tc-nanocolloid (120 megabecquerel; ~0.5 mL). Subsequently, 0.5–1.0 mL gadobutrol was peritumorally injected, and MR imaging was acquired for 30 min. The following day, the identified SLNs were harvested and subjected to a histopathological assessment. The MR lymphography and [^99mTc]Tc-nanocolloid lymphoscintigraphy results were evaluated and compared with respect to those of the SLN identification. The reference standard consisted of a histopathological evaluation of the harvested SLNs, complementary neck dissection specimens, and follow-up data. Results: The MR lymphography detected 16 out of 27 SLNs identified by [^99mTc]Tc-nanocolloid lymphoscintigraphy, revealing an additional SLN that did not harbor metastasis. MR lymphography failed to identify any SLNs in one patient. Of the seven histopathologically positive SLNs detected by [^99mTc]Tc-nanocolloid lymphoscintigraphy, three were identified by MR lymphography. All patients remained disease-free after a median follow-up of 16 months. Compared to [^99mTc]Tc-nanocolloid lymphoscintigraphy, MR lymphography using gadobutrol achieved an SLN identification rate of 59%, a sensitivity of 75%, and a negative predictive value of 86%. Conclusions: MR lymphography using gadobutrol demonstrates limited reliability for SLN mapping in early-stage OSCC. Full article

Background: Lymphatic leaks are well-known complications of major thoracic or abdominal surgeries, which significantly heighten morbidity and mortality rates. While the existing literature provides insights into managing these post-operative leaks, with a step-up approach from conservative measures (CMs) to surgical intervention, there are no standardized treatment guidelines. The purpose of this paper is to offer a management algorithm of post-operative lymphatic leaks based on a systematic literature review (SLR) of the therapeutic effect of Lipiodol lymphangiography (LL), completed by a case series of five patients who underwent LL in our department. Methods: In this IRB-approved study, we conducted an SLR following the PRISMA guidelines, using a PICOS. A quality assessment was performed for each study. The case series consisted of consecutive patients who underwent LL for diagnostic and therapeutic purposes at our institution between September 2018 and December 2020. Results: A total of 39 observational studies were included in the SLR comprising 11 retrospective case reviews (Group 1), and 3 case series as well as 25 case reports (Group 2). In total, these studies report cases of 557 patients (51.52% presenting oncological diagnoses; 43.98% having benefited from lymphadenectomy). Lymphatic or chylous fistulas were the most encountered complication, followed by chylothorax. The median volume of Lipiodol injected during lymphography was 11.7 mL (range: 9.8–75 mL). Overall, LL was technically successful in 77.7% (366/471) of patients. The clinical success of all technically successful LLs was 80.6% (295/366). Time-to-leak resolution after lymphography varied between 1 and 31 days. The factors associated with treatment failure were a high leak output (>500 mL/day) and Lipiodol extravasation on post-LL imaging. Our case series consisted of five patients (mean age: 62 ± 9.24 years; 20% female; 100% oncological diagnoses; 60% having beneficiated from lymphadenectomy). Technical and clinical successes were 80% (4/5) and 75% (3/4), respectively. Time-to-leak resolution varied between 1 and 4 days. The volume and technique of LL was not different from that identified in the SLR. Conclusions: LL is a safe procedure with high technical and clinical success rates that could be proposed as both a diagnostic and therapeutic solution for patients with post-operative central lymphatic lesions. Full article

Background/Objectives: Microsurgery employs techniques requiring optical magnification and specialized instruments to operate on small anatomical structures, including small vessels. These methods are integral to plastic surgery, enabling procedures such as free tissue transfer, nerve reconstruction, replantation, and lymphatic surgery. This paper explores the historical development, advancements, and current applications of microsurgery in plastic surgery. Methods: The databases MEDLINE (via PubMed) and Web of Science were selectively searched with the term “(((microsurgery) OR (advances)) OR (robotic)) OR (AI)) AND (((lymphatic surgery) OR (peripheral nerve surgery)) OR (allotransplantation))” and manually checked for relevance. Additionally, a supplementary search among the references of all publications included was performed. Articles were included that were published in English or German up to June 2024. Results: Modern microsurgical techniques have revolutionized plastic surgery, enabling precise tissue transfers, improved nerve reconstruction, and effective lymphedema treatments. The evolution of robotic-assisted surgery, with systems like da Vinci and MUSA, has enhanced precision and reduced operative times. Innovations in imaging, such as magnetic resonance (MR) lymphography and near-infrared fluorescence, have significantly improved surgical planning and outcomes. Conclusions: The continuous advancements in microsurgery, including supermicrosurgical techniques and robotic assistance, have significantly enhanced the capabilities and outcomes of plastic surgery. Future developments in AI and robotics promise further improvements in precision and efficiency, while new imaging modalities and surgical techniques expand the scope and success of microsurgical interventions. Full article

Lymphedema presents significant challenges to patients’ quality of life, prompting the exploration of innovative treatments, such as collagen scaffolds, aimed at treating and reducing the risk of lymphedema. We aimed to evaluate the preventive and therapeutic efficacy and the lymphangiogenic potential of implanted aligned nanofibrillar collagen scaffolds (BioBridge^TM) following the induction of secondary lymphedema in a rabbit model. Thirty rabbits were divided into treatment (G1), prevention (G2), and control (G3) groups. Secondary lymphedema was induced in all groups. BioBridge^TM implantation was performed in G2 and G1 on days 0 and 60, respectively. Follow-ups included hindlimb circumference measurements and indocyanine green lymphography at 0, 60, and 90 days. None of the study rabbits exhibited dermal backflow on day 0 before surgery. At 60 days, the incidence rates of dermal backflow in G1, G2, and G3 were 100%, 44.4%, and 90%, respectively. Furthermore, at 90 days, the incidence rates were 22.2%, 44.4%, and 90%, respectively. New linear lymphatic observation was seen in rabbits with resolved dermal backflow. The findings of this study demonstrated the capacity of BioBridge^TM scaffolds to induce new lymphatic vessel formation and reduce dermal backflow in secondary lymphedema in a rabbit model. Full article